Pre Medical Examination Format ( MER Form )
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Star Health and Allied Insurance Co. Ltd. Page 1 of 5 Name of the person to be insured: ____________________________________________________________________ Date of birth: _________________ Age: _____________ Sex: Marital Status: ________________ Occupation: _____________________________________ Identification Marks:(1) ________________________________________(2)_________________________________ 1. Measurement & Vitals Height(Cms) Weight (Kgs) BMI Waist Circumference (cms) BP * Systolic Diastolic Pulse Rate /Rhythm Respiratory rate I Reading: II Reading: III Reading: *If the Systolic reading is 140 or more or Diastolic reading is 90 or more, second and third reading should be taken with 10 minutes interval of rest. 2. Personal Physician / Last Consultation: Name and address of your personal physician (if none, state the name of the doctor last consulted) Date of last consultation Reason 3. Past History Details of medical illness in the past Period Details of surgery/procedure undergone in the past MEDICAL EXAMINATION REPORT (To be filled in by the Medical Examiner)
description
Health insurance Examination Report done by Doctor. One can go through before going for pre policy health check up. You will not get policy if policy maker do not find your report health enough to sanction you insurance.
Transcript of Pre Medical Examination Format ( MER Form )
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Star Health and Allied Insurance Co. Ltd.
Page 1 of 5
Name of the person to be insured: ____________________________________________________________________
Date of birth: _________________ Age: _____________ Sex:
Marital Status: ________________ Occupation: _____________________________________
Identification Marks:(1) ________________________________________(2)_________________________________
1. Measurement & Vitals
Height(Cms) Weight (Kgs) BMI Waist Circumference (cms)
BP * Systolic Diastolic Pulse Rate /Rhythm Respiratory rate I Reading:
II Reading: III Reading: *If the Systolic reading is 140 or more or Diastolic reading is 90 or more, second and third reading should be taken with 10 minutes interval of rest. 2. Personal Physician / Last Consultation:
Name and address of your personal physician (if none, state the name of the doctor last consulted)
Date of last consultation Reason
3. Past History
Details of medical illness in the past Period
Details of surgery/procedure undergone in the past
MEDICAL EXAMINATION REPORT (To be filled in by the Medical Examiner)
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Star Health and Allied Insurance Co. Ltd.
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4.(a) If the person to be insured is presently suffering from any of the following diseases, please give details:
DISEASE DURATION & DETAILS OF DRUGS TAKEN
DM/HTN
Orthopedics and related diseases
CVA/Neurological Diseases
Heart Disease/Respiratory Illness
Mental Illness
Renal Disease
Cancer
Other (specify)
(b) Within the past 4 years had he/she undergone any diagnostic test like blood test, ECG, CT Scan, MRI etc.,
If yes, please give details ________________________________________________________________________________
( c ) Details of illness for which OP treatment, IP treatment taken or any check up done during last one year.
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Star Health and Allied Insurance Co. Ltd.
Page 3 of 5
(d) General Examination
Built
Nutrition
Anaemia
Cyanosis
Clubbing
Pedal edema
Lymphadenopathy
Others
5. Examination of systems
SYSTEMS YES NO DETAILS ENT & Opthalmology
Any evidence of cataract or surgery done for cataract (or) Any other visible eye conditions. Are there any missing teeth? If so, give details, Mouth Ulcers, Leucoplakia, etc.,
Are there DNST/T & A/Ear Discharge & Hearing Loss
Respiratory System. Are there any abnormality or diseases of the respiratory system like TB, Asthma, COPD etc.?
Cardiovascular System Is examination of CVS normal ?
Abdomen Is there any organomegaly ?
Any Ascites
Surgical Scar if any
Is there any evidence of Hernia, hydrocele, undescended testis, chronic ulcer etc.,
Nervous Systems Is there any evidence of neurological disorder such as epilepsy, wasting, involuntary movements, paralysis etc.,
Muscle Skeletal System Examination of limbs, spine & joints
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Star Health and Allied Insurance Co. Ltd.
Page 4 of 5
SYSTEMS YES NO DETAILS For female only Is there any disease of the breasts? ( Lump ) Do you suspect any disease of ovaries uterus, cervix
6( a) Family History: Parents
Parent If alive If NOT alive
Age Present Health Status Age at death Cause of Death
Father
Mother
(b) Family History: Diseases of parents
If any other family member is suffering from any of the following diseases, please give details
Relationship with the person to be insured
DM HTN CVA Heart Disese
Renal diseases
Cancer Mental Illness
Others (Please specify)
Medical Examiners Opinion :
Are there any Pre-Existing diseases? If yes , give details
Any other remarks.
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Star Health and Allied Insurance Co. Ltd.
Page 5 of 5
Is the person to be insured, related or known to Medical Examiner? Yes/No Signature of the person to be insured. Name of the Medical Examiner. Signature & seal. Place:_________________ Date:____________ Address:____________________________
To be filled in by the Companys doctor/Panel doctor
Details of pre-existing diseases of the person to be insured to be incorporated in the policy:-
(1)
(2)
(3)
Name of doctor: __________________ Signature and Seal: _________________
Place: _______________ Date: ____________ Address:____________________________
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