Medical Application Form Page 4
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4Medical Conditions
Name of applicant
Age:
Sex:
Date of application:
/
/
(dd/mm/yyyy)
Medical condition/diagnosis:
(if more than one sickness, please complete a separate form for each)
Date of last treatment/symptoms:
/
/
ongoing treatment = current date
(dd/mm/yyyy)
Diagnosis Status:
Yes
No
Cured/ no symptoms
•
Ongoing symptoms
•
Ongoing hospitalization
•
Pending hospitalization
•
Ongoing treatment
•
Pending treatment
•
In case of any Diagnosis Status the applicant was treated as:
Outpatient
•
Hospitalized
•
Treated both ways
•
Operated on:
/
/
(dd/mm/yyyy)
•
How often do the symptoms occur?
Or can the illness be described as follows?
Acute
•
Chronic
•
Recurrent
•
Did you have any bone fractures or injuries to bones or tendons?
Has any material used for osteosynthesis etc. been removed?
In case medication is required on a regular basis please specify the genuine name, the brand name as well
as the daily/weekly quantity below.
In case you are suffering from hypertension please specify your Systolic and Diastolic readings below.
Systolic:
Diastolic:
In case of diabetes please specify whether insulin dependent.
Date:
Signature:
ORIENT INSURANCE PJSC
P.O. Box 27966, Dubai – UAE
Tel.: +971 4 253 1300 Fax: +971 4 251 5079
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