attending physician’s statement personal · pdf fileform id version 01/2018 page 1/4...

FORM ID Version 01/2018 /4

NRIC/Old IC/Passport/Birth Cert/Other

ATTENDING PHYSICIAN’S STATEMENT - PERSONAL ACCIDENT CLAIMNote: This form is to be completed by the Attending Doctor at the Patient’s expense

Policy Number

Gender

11601004Prudential Assurance Malaysia Berhad (107655-U)

Level 17, Menara Prudential, No. 10, Jalan Sultan Ismail,50250 Kuala Lumpur. P.O. Box 10025,50700 Kuala Lumpur.Customer Service Hotline: 603-2116 0228, Fax: 603-2032 3939, E-mail: [email protected]

Patient's Name

Date of Birth

SECTION A : Medical History of the Patient Please utilise the blank space below to provide any additional information regarding the patient’s condition.

1. Occupation

Day Month Year

3. Date of Accident as related by the patient

7. Based on your professional opinion, are the patient’s current bodily injury (ies) consistent with the description / nature of the accident ?

If not, are they traceable to any pre-existing condition, previous injuries not related to this accident or any other cause known to you (Please specify)

8. Is the patient now, or was he/she at the time of the accident suffering from any illness, disease or infirmity/ physical deformity/intoxication?

YES NO If yes, please state the nature and to what extent his/her recovery has been or may be retarded thereby.

FemaleMale

2. Nature of occupational duties

Time

Day Month Year

4. Date of First Consultation

Time

5. Describe in detail the nature of accident as related to you by the patient

6. Were there any external and visible injuries or wounds as a result of this accident?

YES NO

If Yes, then please describe the extent of injuries including site and other characteristics or features as seen by you.

If no, please describe any other evidence that is consistent with the accident as claimed by the patient

In the event of any amputation, please state at what level (eg: proximal, middle, distal) You may use the diagram in page 3 to illustrate the level of amputation and percentage of loss.

Yes No

9. Was any X-ray or any other investigatory tests taken? YES NO

If yes, please supply a copy of the Radiologist or related reports for our reference.

Prudential Assurance Malaysia Berhad (107655-U)Level 17, Menara Prudential, No. 10, Jalan Sultan Ismail,50250 Kuala Lumpur. P.O. Box 10025,50700 Kuala Lumpur.

Customer Service Hotline: 603-2116 0228, Fax: 603-2032 3939, E-mail: [email protected] ID 11601004

Please utilise the blank space below to provide any additional information regarding the patient’s condition.

10. What is the final diagnosis of the patient upon your clinical findings and / or investigating tests results

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e) Treatment given including follow-ups:

Date of Consultation (DD/MM/YYYY)

Details/Conditions of Physical Injuries

Details of Treatment ( Eg Dressing, Incision

and Drainage, Medication

Prescribed, etc )

Details of limitation / physical disability (eg. Range of movement, condition of wound,

etc )

11. Details of injuries and all treatment prescribed. Please include the following information ( where applicable )

a) Number of Stitches

b) Date of Removal of Stitches

c) Type of Dressing

d) If patient was put on any form of immobilization (POP, backslab, crepe bandage, etc), please furnish us the following :

Day Month Year

i) Date First Applied

Date of Removal

Day Month Year

Day Month Year

ii) Date Started Physiotherapy

Date of Completion

Day Month Year

Day Month Year

Day Month Year

Day Month Year

iii) Date Started Full Weight Bearing

Date of Completion

iv) Details of Limitation of Movements on any joints (please specify)

Details of Healing Progress




f. Please illustrate the injuries in the following diagrams

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12. Date of Last Consultation

Condition of the injured part(s):

Day Month Year

13. Was the healing (Straight forward / Complicated)?

Straight Forward Complicated

If complicated, please provide details of complication/s.

14. Details of Hospitalisation (if any):

a) Name of Hospital:

b) Admission No:

c) Date Admitted:

d) Date of Discharged:

e) Date of Surgery Performed:

f) Type of Surgery Performed:

Day Month Year

Day Month Year

15. Name and address of other doctors who treated the patient for the same injury, and the date of treatment




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The reason(s) for completing the above mentioned information on behalf of the Attending Doctor:

I hereby certify that:

I am the patient’s attending doctor and I have personally examined and treated the patient; OR I have personally perused the patient’s medical records;

and that the facts as stated above are all true to the best of my knowledge and information.

If you are not the attending doctor, please state:

The Attending Doctor’s Name & Speciality:

: Date :

:

Signature of Doctor

Name

Professional Qualification :

: Name & address of hospital/ clinic

Hospital’s/ Doctor’s Stamp :

SECTION B : Attending Doctor's Declaration

16. For Females Only: a) Was the patient pregnant at the time of accident?

Yes No

If yes, for how many weeks /months?

b) Was the accident caused directly or indirectly by the pregnancy? If yes, please describe in detail.

16. Is patient employed at the time of the accident? Yes No

If No, please indicate in the boxes below which “Activities of Daily Living” that patient unable to perform: (either with or without the use of mechanical equipment, special devices or other aids and adaptations)

Transfer(Getting in & out of chair without requiring physical assistance)

Mobility(The ability to move from room without requiring any physical assistance)

Continence(The ability to voluntarily control bowel and bladder function such as to maintain personal hygiene)

Dressing(Putting on and taking off all necessary items of clothing without requiring assistance of another person)

Bathing/Washing(The ability to wash in the bath or shower (including getting in or out of the bath or shower) or wash by any other means)

Eating(All tasks of getting food into the body once it has been prepared)

attending physician’s statement personal · pdf fileform id version 01/2018 page 1/4...

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