MEDICAL EXAMINATION REPORT

Customer Name: Abhijeet gopalan Date: 09-01-2021

Date of Birth: 19-07-1992 Age : 29
_______Years Sex: M / F Customer Contact No.: 9654673497
1. Please confirm whether all tests completed as per test list?If No: No
Yes
Pls mention reason and test details:

2. Please confirm whether all samples provided for Health Check-Up?If No: Yes No
Pls mention reason and sample details:

3. Past Medical History: Does the individual have any past history of any of the following? If Yes, Pls provide details of
medication, surgery, procedures and hospitalization (if any).
Ailments Yes No If Yes, Date If Yes, Medicine, Treatment
Details
a. Hypertension

b. Diabetes Mellitus (Type 1/Type II)

c. Thyroid Problems
d. Cardiac or Heart Problems / Vascular
(Artery/Vein) Ex DVT, Varicose, Arterial Blocks.
Myocardial infarction or Heart valve problems or
septal defects

e. Renal Failure, Dialysis, Other Kidney, Urinary Tract,

Prostate diseases or stones in Urinary System

f. Arthritis, Spondylosis, Spondylitis, Joint Pains, Joint

Replacements or Any other disorders of
Bone/Joint/Muscles

g. Tuberculosis, Asthma, Bronchitis, COPD, or Any

other Lung/Respiratory Diseases
h. Liver Disease or Any Other Gastro Intestinal,
Digestive system or Gall Bladder Disease
i. Tumor-Benign or Malignant, any other Brain/Nervous
System Disease
j. Stroke, Epilepsy, Paralysis, Parkinsons or Any other
Brain/Nervous System Disease
k. Fibroid / Cyst / Fibroadenoma, Bleeding Disorder of
uterus, Pelvic infection or any other Gyneacological /
Breast Disorder (only for Females)

l. Any other illness / Surgery / Symptoms or treatment

taken by individual (If Yes, please specify name of the
Drug and dosage)

m. Any Congenital or Genetic illness

n. Does the customer have any habits Alcohol (l) Per Day : Since
Tobacco Chewing Per Day : Since
Cigarettes/Bidi Per Day : Since
4. Does the individual have a family history of any (like
Heart disease/ brain Disease / cancer / organ failure /
autoimmune disease /genetic disorder etc.)?
I hereby declare and affirm that the above mentioned facts are true and correct to the best of
my knowledge and nothing material has been concealed therefrom.
Name of the Customer : Abhijeet gopalan Medical Officer
Sign & Stamp
Sign of the Customer:
5.Please tick the below wherever applicable:
Ailments Yes No If Yes, Onset Month If Yes, Medicine Name,
& Year treament details
a) Joint Problems
b) Hernia : Any evidence
c) Skin Disease/Tumor/Growths
d) Vision/Hearing Abnormality
PHYSICAL EXAMINATION:
6. General Examination:
f) Any Defect/Deformity:
a) Height : ________________
170 Cms
b) Weight : ________________
75 Kgs g) Any Evidence of below (Please tick wherever applicable)
c) Pulse : ________________/min Anaemeia : Pedal Edema:
d) BP :________________mm/hg Icterus : Clubbing
e) BMI : ________________
26.0 Cyanosis : Enlarged
Enlarged Thyroid : Lymphnodes :
h. Any other positive findings on general
examination :
7. Systemic Examination:
System Examination Findings
a) Respiratory System: Normal
b) Cardiovascular System : Normal
c) Per Abdomen : Normal
d) Central Nervous System: Normal
e) Musculoskeletal System: Normal
Please detail all the positive findings :
Bmi high, overweight
8. For Females Only :
Any evidence of problems related to Uterus / Breast / Ovaries / NA
Cervix / Abnormal bleeding : If Yes, Please give details:

Declaration: I hereby declare and affirm that the above mentioned facts are true and correct to the best of my knowledge and nothing
material has been concealed there from.

Doctor Details
Name of Attending Doctor : Nikhil Yewale Sign of the Doctor:
Degree/Registration No.: Internal Medicine
Place: Mumbai Date: 09-01-2021 Rubber Stamp of Doctor:
Disclaimer: Any discrepancy or Non-Disclosure of medical facts recorded in this document which is evident
at the time of claims will be deemed to be non disclosure / misrepresentation of material facts leading to policy
cancellation and making the claim liable for rejection on the grounds of breach of policy terms and conditions
and misrepresentation of facts.

Feedback (to be filled by the customer)

Please Rate your experience on the following parameters from 1 to Poor Below Average Good Excellent
5, 5 Being the best 1 Average 2 3 4 5
Kindly rate the conduct of staff, Hygiene, Infrastructure & Service levels of
Diagnostic Centre/Hospital
Experience on Appointment scheduling and response time

Experience & turnaround time of Health check Up Procedure

Overall, how satisfied you are with the health check up program with ICICI
Lombard?
Any other suggestions to improve our services:

Name of the Customer: Sign of the Customer:

Abhijeet gopalan
 Patient/Customer Other Parameters ECG Details (Lead II) Recorded 09-Jan-2021 10:23 AM

Name Average Heart Rate QRS Complex 63 ms Device CTO06218AM0079

Abhijeet Gopalan 82 bpm
ST Segment 122 ms QRS Axis Normal
Gender Male BP Systolic
133 mmHg T Wave 191 ms X Axis 1 Sec = 25 mm
Age 29 BP Diastolic Y Axis 1 mV = 10 mm
ID 91202110184057134 70 mmHg QT Interval 377 ms
QTc Interval 522 ms
RR Interval 783 ms

aVR

V4
I

V2

aVL V5
II

V1

V3
III aVF V6

II
0 Sec 75 Sec 76 Sec 77 Sec 78 Sec 79 Sec 80 Sec 81 Sec 82 Sec 83 Sec 84 Sec 85 Sec

Referred doctor: DHARMAPALA B V ,Specialist Remark: Reviewed By:

Normal ECG

Dr. Anirban Bhowmik

M.B.B.S, P.G.D.C.C
Reg. No - ASS20090000010KTK
*Electronic Signature
©2016 uber Diagnostics Pvt. Ltd. page 1
Patient/Customer Other Parameters ECG Details (Lead II) Recorded 09-Jan-2021 10:23 AM

Name Average Heart Rate QRS Complex 63 ms Device CTO06218AM0079

Abhijeet Gopalan 82 bpm
ST Segment 122 ms QRS Axis Normal
Gender Male BP Systolic
133 mmHg T Wave 191 ms X Axis 1 Sec = 25 mm
Age 29 BP Diastolic Y Axis 1 mV = 10 mm
ID 91202110184057134 70 mmHg QT Interval 377 ms
QTc Interval 522 ms
RR Interval 783 ms

PARAMETER READING STATUS PARAMETER READING STATUS

OXYGEN SATURATION (%) Not Captured FVC (L) Not Captured
BLOOD PRESSURE SYSTOLIC (mmHg) 133 ABNORMAL FEV1 (L) Not Captured
BLOOD PRESSURE DIASTOLIC (mmHg) 70 NORMAL FEV6 (L) Not Captured
HEART RATE (bpm) 82 NORMAL FEV1/FVC (%) Not Captured
BODY TEMPERATURE (DegC) Not Captured FEF2575 (L/s) Not Captured
WEIGHT (KILOGRAMS) Not Captured PEF (L/m) Not Captured
HAEMOGLOBIN Not Captured SMOKER Not Measured
BLOOD SUGAR (R) Not Captured MALARIA TEST Not Measured
BODY MASS INDEX Not Captured HIV TEST Not Measured
BODY FAT (%) Not Captured DIABETES TEST Not Measured
BODY WATER (%) Not Captured HYPERTENSION Not Measured
BONE MASS+MUSCLE MASS (%) Not Captured OBESITY Not Measured
LEAN MASS (%) Not Captured NOTES Not Captured
WAIST:HIP RATIO Not Captured
WAIST:HEIGHT RATIO Not Captured
WAIST CIRCUMFERENCE (cm) Not Captured
ABDOMEN CIRCUMFERENCE (cm) Not Captured
CHEST CIRCUMFERENCE (cm) Not Captured
HIP CIRCUMFERENCE (cm) Not Captured
HEIGHT (cm) Not Captured
TOTAL CHOLESTEROL (mg/dl) Not Captured
SYMPTOMS Not Captured

Referred doctor: DHARMAPALA B V ,Specialist Remark: Reviewed By:

Normal ECG

Dr. Anirban Bhowmik

M.B.B.S, P.G.D.C.C
Reg. No - ASS20090000010KTK
*Electronic Signature

©2016 uber Diagnostics Pvt. Ltd. page 2