Prudential Assurance Co. - Hospital Claim Form Page 4
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46. a)
The prognosis of the condition: GOOD / FAIR / POOR
b)
Any possibility of having a relapse?
Yes / No
:
/
/
?
/
7.
Was the patient's injury / illness directly or indirectly due to or aggravated by the following:
:
Yes, please tick where it is appropriate and give details.
No
(
) alcoholism/alcohol/narcotics/drug
(
) hazardous sport/activity
(
) cosmetic or plastic surgery
/
/
(
)
(
)
(
)
self-inflicted injury
mental disorders
congenital/inherited condition
/
(
)
(
)
(
)
pregnancy/childbirth
weeks
AIDS/AIDS related complex disease
corrective aids or treatment of
/
refractive errors
/
(
)
(
)
(
)
infertility/sterilization/termination of pregnancy
body check / vaccination & immunization injections
rehabilitation / convalescence
/
/
/
/
(
)
others, please specify
Please provide details:-
:-
8. Did you refer the patient to another physician/hospital?
?
Yes, please give the name and address of the physician / hospital and provide details for referral reason.
No
9.
Other than this episode, has the patient ever been treated for the
same/related conditions
?
?
Yes, please provide details.
No
Consultation Date (DD/MM/YY)
Physician / Hospital
Diagnosis
Details of Treatment(s)/Hospitalization
/ /
/
/
10.
a)
Did the patient has the following
medical history/habit?
/
?
PAST
No
Yes, please tick where it is appropriate and give details.
(
)
(
) asthma
(
) cardiac problem
(
) diabetes mellitus
(
) drinking habit
(
) hepatitis B
(
) hypertension
(
) unfavorable family history
(
) smoking
(
) previous operation
(
) drug addiction
(
) others, please specify
b)
By whom was the above
past
medical history first detected?
/
c)
Please provide first diagnosis date and treatment details of the above
past
medical history.
d)
Current Prognosis of the above past medical history:
Fully recovered
On treatment
Not quit
Quit, since
e)
Present smoking/drinking status
/
DD/MM/YY
/
/
11. Other information.
Name of Physician
Qualification
Hospital Name (if applicable)
Contact Phone No.
(
)
Address
Signature & Hospital/Physician Chop
Date (DD/MM/YY)
/
( / /
)
chpfrm0104
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