Pediatrician Report

Questions relating to Proposed Insured

Last Name First Name Extension Name Middle Name

Date of Birth (mm/dd/yyyy) Gender

Birth History, including the pregnancy history of the mother

________________________________________________________________________________________________________________________________
Vaccination history

________________________________________________________________________________________________________________________________
Developmental history- Physical, Mental and Motor

________________________________________________________________________________________________________________________________
Family history -Parents or 2 or more siblings of the child suffer from or died due to bronchial asthma, tuberculosis, hypertension, tumor/cancer, diabetes
mellitus, mental/ psychiatric disorder or any other hereditary disease? 〇 YES 〇 NO, if yes, provide details below

Medical Condition Family Member Age at Onset Status

Please tick off the appropriate answer, encircle the specific item in the question and provide the details in the space provided for
Have the child ever had or been treated for: Please provide details as follows: (Item no.,
Diagnosis, ,Date of Diagnosis, Drugs or
Treatment , Result of Treatment and
Prognosis)

a. Disease of eyes, ears, nose or throat? 〇 YES 〇 NO

b. Mental or nervous disease, dizziness, fainting, epilepsy, convulsions, headache, 〇 YES 〇 NO
paralysis or other disease of the brain?
c. Congenital heart disease, chest pain, palpitation, abnormal blood pressure, 〇 YES 〇 NO
rheumatic fever, heart murmur, or other disease of the heart or blood vessels?
d. Asthma, bronchitis, shortness of breath, persistent hoarseness or cough, 〇 YES 〇 NO
tuberculosis, pneumonia or other disease or other disease of the lungs?
e. Indigestion, ulcer, colitis, jaundice, hepatitis, diverticulitis, hernia, or other disease 〇 YES 〇 NO
of the stomach, intestines, Liver, gall bladder, pancreas, or been found to be a
Hepatitis B carrier?
f. Arthritis, gout, neuritis, or sciatica, or injury or disease of the muscles, bones or 〇 YES 〇 NO
joints including the back and neck?
g. Sugar, albumin, blood or pus in the urine, renal colic or other disease of the 〇 YES 〇 NO
kidneys, bladder, reproductive organs?
h. Diabetes, thyroid, pituitary, adrenal or other glandular disease? 〇 YES 〇 NO
i. Deformity or amputation? 〇 YES 〇 NO
j. Cancer, tumour, cyst, disease of the skin or lymph gland? 〇 YES 〇 NO
k. Allergies, anaemia, hemophilia or other disease or disorder of the blood? 〇 YES 〇 NO
l. A positive test or scheduled to undergo any test for Human immune –deficiency 〇 YES 〇 NO
virus (HIV), acquired immunodeficiency syndrome (AIDS) or AIDS related
complex?
m. A blood transfusion? 〇 YES 〇 NO
n. Been advised to have an operation or contemplate surgery in the future? 〇 YES 〇 NO
I, the Owner, do hereby declare the statements and answers concerning the proposed insured are complete and true, that they are correctly and fully recorded
and that no material information has been withheld or omitted concerning his/her past and present state of health and I agree that this declaration shall form
part of the Application for insurance for the Proposed Insured made to FWD Life Insurance Corporation.

Signed on this day of ___________________ at ____________________________________________________________________________________________

___________________________________________________________________________________________________________________________________
Printed Name and Signature of Owner

___________________________________________________________________________________________________________________________________
Printed Name and Signature of Attending Pediatrician
 PEDIATRICIAN’s CONFIDENTIAL REPORT

Are you the personal paediatrician of this child? If so, for how long? _______________________________________________

Is there anything unfavourable in his/her appearance or development? _______________________________________________

Give particulars on any permanent marks. _______________________________________________

1. Give the following measurements?

Height (inches) __________ Weight (pounds) ___________
Chest circumference (inches) __________ Abdominal girth (inches) ___________ at Umbilical level, next skin (inches) _________
2 a. Is there any defect in sight, hearing or speech? In cases of
present or past ear discharge or deafness, state result of auriscopic a. _______________________________________________
examination?
b. Is there abnormality of tongue, mouth or throat? b. _______________________________________________

3. Is there any abnormality of the respiratory system to palpation,

percussion or auscultation? If so, give particulars. _______________________________________________
4. a. What is the rate and character of the pulse? a. _______________________________________________
Pulse Rate __________ per min.
b. What is the position of the apex best of the heart? b. _______________________________________________
c. Is there evidence of cardiac enlargement? c. _______________________________________________
d. Is there any abnormality in the heart sounds or rhythm? If so, d. _______________________________________________
give particulars
e. If any murmur is present, describe fully including site, timing, e. _______________________________________________
intensity and transmissions.
Also, indicate any effect of posture or respiration on the f. First BP __________ mm Hg __________ mm Hg
murmur. Second BP __________ mm Hg __________ mm Hg
f. What is the Blood Pressure? (if under treatment with drugs, Third BP __________ mm Hg __________ mm Hg
please specify)
g. _______________________________________________
g. Do you consider the heart and vascular system to be normal?
5. a. Is there any abnormality or evidence of disease of any
abdominal organ, including liver and spleen a. _______________________________________________
b. Is hernia present? If so, describe fully and state whether a
satisfactory truss is worn? b. _______________________________________________

6. a. Do you consider the genito-urinary system to be normal and

and healthy? a. _______________________________________________
b. Is hernia present? If so, describe fully and state whether a
satisfactory truss is worn? b. _______________________________________________
7. Is there any abnormal reflex or other evidence of disease of the brain,
nerves or spinal cord? If so, please state circumstances. _______________________________________________
8. Is there any abnormality of the muscles, bones or joints, including the
back and neck? _______________________________________________
9. Is there any abnormality of lymph glands in the neck, axillae or inguinal
region? _______________________________________________
Summary
a. Please comment fully on any unfavorable features in the personal
or family history or disclosed by your medical examination. a. _______________________________________________
b. Do you consider any reports or special tests are required? b. _______________________________________________
c. Do you consider the applicant to be predisposed to any particular
disability, ailment or likely to require surgical operation? c. _______________________________________________

I certify that I have examined the Proposed Insured on this day of _________________ at _______________________________________ and I have also
reviewed all answers on this and on the reverse side and believe them to be correctly recorded, complete and true.

Signature of Medical Examiner ___________________________________ Printed name of Medical Examiner__________________________

PRC No. ______________________________________________________

PDR Form 11/11/15 -001