ASIA UNITED INSURANCE, INC. ATTENDING PHYSICIAN’S REPORT | 0 Patient's Name Sex Age 2)_Nature of liness or injury ‘@) Chief complaint i | | Frags | 6) Brief History of Present lines @) Complication, any ~~ @) If here any facture or dsiocaton,slale whathor Complete or complete 1) floss of sight, check whether: () Right Eye () Left eye (/) Both Eye () Entire and irrecoverable () Partial & recoverable "When dia Symptoms fist appear or accident happen? (9) When dia patent frst consul you Tor this condition? '"5)” Nature of surgical procedure, if any. (Describe fully) \9 . Was patient hospitalized? () Yes () No i Hospital: Date Admitted | Address: Date Discharged: | 7) How Tong was or will patient be continuously totally disabled (Unable to work) 7 | From Through | 8)" Ws condition due to injury related to the accident: () Yas 7) No Signature Printed Name ‘Bitending Physician) IMPORTANT Panes Attending Physician must sign on inca an this Attending Physician's Report ares TIN, LABORATORY EXAMINATION MEDICATIONS / PRESCRIPTIONS