Annexure for Post - Covid Wellness

(To be filled by the Medical Examiner from Kotak Empanelled Center)

Name - Policy No -

1. Please confirm the date of diagnosis of covid-19 :

2. Did life assured visit any doctor post covid-19 illness for any health reasons? If so, please provide
details including presenting symptoms, investigations done, diagnosis, treatment given, follow –
ups done, etc.

3. Please confirm whether life assured suffers/suffered from any illnesses/issues, including but not
limited to:
 Chronic fatigue – Yes / No
 Breathlessness at rest/light work/exercise – Yes / No
 Worsening of chronic illnesses – Yes / No
 Any psychological disorders including insomnia, anxiety, panic attacks etc – Yes / No
 Any cognitive impairment – Yes / No
 Chronic/continuous pain – Yes / No
 Poor endurance – Yes / No
 Any myopathy/neuropathy – Yes / No
 Any pulmonary manifestations of covid-19 – Yes / No
 Any indication/sequelae of hyper-coagulation of blood – Yes / No
 Impaired renal function – Yes / No
 Any indication of myocardial injury – Yes / No
 Any other issue not mentioned above – Yes / No

If answered yes to any of the above mentioned questions, please provide details
 4. On treatment of Covid-19, Please comment on severity of illness, treatment given & current status
of life assured

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Declaration by Medical Examiner:

I hereby certify that I have personally identified, interviewed & examined the above examinee, on the
date & place mentioned below. I have recorded the entire true and correct details as above. I have not
withheld any information disclosed by the examinee nor any examination findings, as a physician.

Dated …………………………………………… Place …………………………………………………………………………………....

Stamp & Signature of the Medical Examiner with KLI Stamp …………………………………………………………….