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  • Aditya Birla Health Insurance Co. Limited

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    Mohammed Bilal Shaik
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    This document contains information about a health assessment conducted by Aditya Birla Health Insurance Co. Limited. It includes details about the policyholder such as name, gender, date of birth, and identification documentation. It also lists body parameters that were measured such as waist circumference, blood pressure, and whether the person smokes or chews tobacco. Laboratory tests conducted include fasting blood sugar. The policyholder declares that the information provided is true and complete. The medical professional conducting the examination also declares they have verified the identity of the policyholder and that nothing has been misrepresented.

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    Health_Assesment_Form_31-12-2020

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    This document contains information about a health assessment conducted by Aditya Birla Health Insurance Co. Limited. It includes details about the policyholder such as name, gender, date of birth, and identification documentation. It also lists body parameters that were measured such as waist circumference, blood pressure, and whether the person smokes or chews tobacco. Laboratory tests conducted include fasting blood sugar. The policyholder declares that the information provided is true and complete. The medical professional conducting the examination also declares they have verified the identity of the policyholder and that nothing has been misrepresented.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    11 views1 page

    Aditya Birla Health Insurance Co. Limited

    Uploaded by

    Mohammed Bilal Shaik
    This document contains information about a health assessment conducted by Aditya Birla Health Insurance Co. Limited. It includes details about the policyholder such as name, gender, date of birth, and identification documentation. It also lists body parameters that were measured such as waist circumference, blood pressure, and whether the person smokes or chews tobacco. Laboratory tests conducted include fasting blood sugar. The policyholder declares that the information provided is true and complete. The medical professional conducting the examination also declares they have verified the identity of the policyholder and that nothing has been misrepresented.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    Health Insurance

    Aditya Birla Health Insurance Co. Limited


    (A subsidiary of Aditya Birla Capital Ltd.)

    Health Assessment

    Policy Number Member/Client Number

    Member Information :

    Name:

    Gender: Male Female Transgender Date of birth: D D M M Y Y Y Y

    Identification:
    Identity of the examinee has been verified by the way of:

    PAN Card Passport Driving License Election Card

    Aadhaar card Any other authorized document (specify) _______________________________________________________________

    Body Parameters Reading Reading


    Waist Circumference (cm)
    Hip Circumference (cm)
    Hip Waist Ratio (HWR)
    Blood Pressure (3 readings in interval of 5 minutes) Reading 1 - Systolic/Diastolic
    Reading 2 - Systolic/Diastolic
    Reading 3 - Systolic/Diastolic
    Do you or anyone you live with Smoke? Non-Smoker
    Ex-Smoker
    I Have lived with a smoker most of my life
    1 to 14 per day
    More than 15 per day
    Do you chew Tobacco Yes No
    Testing done on fasting blood sugar? Yes No

    In Time:____________Out Time:_____________

    Declaration

    I confirm that all of the above answers and statements are true and I,___________________ herein declare that I have conducted the
    complete to the best of my knowledge and belief and no material physical examination of ______________________________________
    facts concerning my past and present state of health and habits have aſter due verification of his/her identity I further affirm that nothing
    been withheld & omitted. I also agree that any doctors, whether has been misrepresented or concealed by me. I understand that the
    named above or not, who has attended or examined me or who may findings of the physical examination are significant since the findings
    do so hereaſter shall be and is hereby authorized and directed by me are relevant for assessment of risk by the company and shall form
    to disclose to the Company any information he may have acquired part of the contract between the applicant and the company.
    with regard to myself.

    Date : D D M M Y Y Y Y Date : D D M M Y Y Y Y

    Customer Signature Signature & Diagnostic Centre Seal

    Aditya Birla Health Insurance Co. Limited. IRDAI Reg.153. CIN No. U66000MH2015PLC263677.
    Address:- 9th Floor, Tower 1, One World Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg,
    Elphinstone Road, Mumbai 400013. Email: care.healthinsurance@adityabirlacapital.com, Contact us:
    Website: adityabirlahealthinsurance.com, Telephone: 1800 270 7000. Trademark/Logo Aditya Birla Capital is owned by
    1800 270 7000
    Aditya Birla Management Corporation Private Limited and Trademark/logo HealthReturns, Healthy Heart Score and
    Active Dayz are owned by MMI Group Limited. These trademark/Logos are being used by Aditya Birla Health Insurance
    Co. Limited under licensed user agreement(s). adityabirlacapital.com 7

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