Orignal 2
Orignal 2
2. Please confirm whether all samples provided for Health Check-Up?If No: Yes No
Pls mention reason and sample details:
3. Past Medical History: Does the individual have any past history of any of the following? If Yes, Pls provide details of
medication, surgery, procedures and hospitalization (if any).
Ailments Yes No If Yes, Date If Yes, Medicine, Treatment
Details
a. Hypertension
n. Does the customer have any habits Alcohol (l) Per Day : Since
Tobacco Chewing Per Day : Since
Cigarettes/Bidi Per Day : Since
4. Does the individual have a family history of any (like
Heart disease/ brain Disease / cancer / organ failure /
autoimmune disease /genetic disorder etc.)?
I hereby declare and affirm that the above mentioned facts are true and correct to the best of
my knowledge and nothing material has been concealed therefrom.
Name of the Customer : Abhijeet gopalan Medical Officer
Sign & Stamp
Sign of the Customer:
5.Please tick the below wherever applicable:
Ailments Yes No If Yes, Onset Month If Yes, Medicine Name,
& Year treament details
a) Joint Problems
b) Hernia : Any evidence
c) Skin Disease/Tumor/Growths
d) Vision/Hearing Abnormality
PHYSICAL EXAMINATION:
6. General Examination:
f) Any Defect/Deformity:
a) Height : ________________
170 Cms
b) Weight : ________________
75 Kgs g) Any Evidence of below (Please tick wherever applicable)
c) Pulse : ________________/min Anaemeia : Pedal Edema:
d) BP :________________mm/hg Icterus : Clubbing
e) BMI : ________________
26.0 Cyanosis : Enlarged
Enlarged Thyroid : Lymphnodes :
h. Any other positive findings on general
examination :
7. Systemic Examination:
System Examination Findings
a) Respiratory System: Normal
b) Cardiovascular System : Normal
c) Per Abdomen : Normal
d) Central Nervous System: Normal
e) Musculoskeletal System: Normal
Please detail all the positive findings :
Bmi high, overweight
8. For Females Only :
Any evidence of problems related to Uterus / Breast / Ovaries / NA
Cervix / Abnormal bleeding : If Yes, Please give details:
Declaration: I hereby declare and affirm that the above mentioned facts are true and correct to the best of my knowledge and nothing
material has been concealed there from.
Doctor Details
Name of Attending Doctor : Nikhil Yewale Sign of the Doctor:
Degree/Registration No.: Internal Medicine
Place: Mumbai Date: 09-01-2021 Rubber Stamp of Doctor:
Disclaimer: Any discrepancy or Non-Disclosure of medical facts recorded in this document which is evident
at the time of claims will be deemed to be non disclosure / misrepresentation of material facts leading to policy
cancellation and making the claim liable for rejection on the grounds of breach of policy terms and conditions
and misrepresentation of facts.
Please Rate your experience on the following parameters from 1 to Poor Below Average Good Excellent
5, 5 Being the best 1 Average 2 3 4 5
Kindly rate the conduct of staff, Hygiene, Infrastructure & Service levels of
Diagnostic Centre/Hospital
Experience on Appointment scheduling and response time
Overall, how satisfied you are with the health check up program with ICICI
Lombard?
Any other suggestions to improve our services:
aVR
V4
I
V2
aVL V5
II
V1
V3
III aVF V6
II
0 Sec 75 Sec 76 Sec 77 Sec 78 Sec 79 Sec 80 Sec 81 Sec 82 Sec 83 Sec 84 Sec 85 Sec