Juvenile - FMR - PDF For MINOR

LIFE INSURANCE CORPORATION OF INDIA
JUVENILE FMR
Zone Division Branch
Proposal No.
Agent/D.O. Code: Introduced by: (name & signature)
Name of the child: (Master/ Miss)

Mark of identification: Mole/Scar/any other (specify location)
Current ID Student Passport Latest School Report Card Others(specify)
provided
Age of the child: ___________Years/Months SEX: M / F
Birth History: FTND / Forceps / Caesarean/ Other ( Please tick the relevant)
A. Details of Physical Examination

For all children:
Height of the child: _______ cms Weight of the child: _____ kgs
Pulse and character __________ Blood Pressure __________ mm of Hg
Presence of any congenital defects or abnormalities: Yes / No
( If yes, please provide details)
For Children Below 2 yrs:

Head Circumference ___________ cms Chest Circumference ___________ cms
B. Medical History:
1) Is the proposed insured presently in good health? Yes / No
2) Does the proposed insured have any physical and mental Yes / No If yes provide details:
handicap or deformity?
3) Has the proposed insured been hospitalized and/or has Yes / No If yes provide details of
been advised for any treatment/surgery and/or has the
undergone any general checkup in the last five years? tests conducted and treatment if
any.
4) Has the proposed insured ever been treated or hospitalized Yes / No If yes provide details:
for any Heart ailment/cancer/ kidney disorder/ epilepsy/
mental disorder/ diabetes/ musculoskeletal disorder/ blood
disorder/ respiratory disorder like Bronchitis or
Asthma/congenital or hereditary disorder
5) Is the child’s behavior / appearance / mental ability in line Yes / No If yes provide details:
with his current age?
6) If school going, has proposed insured taken any sick leave Yes / No If yes provide details:
from school in the last 2 years?
7) Please give details of proposed insured’s family history : Father:
Is any family member/s either suffering or have suffered or Mother :
have died from heart disease, thallassaemia, cancer, kidney Sibling 1
disease, any other hereditary / familial disorders Sibling 2
C. Immunization History: (Mandatory for ages < and equal to 5 yrs)

Vaccinated for
1. OPV: Yes / No 2. DPT: Yes / No
3. BCG: Yes / No 4. Hepatitis B: Yes / No
5. Mumps, Measles, Rubella: Yes / No 6. Typhoid (above 1 Yr): Yes / No
7. Hepatitis A ( Above 1 Yr) : Yes / No
D. Medical Examination
Do you find any evidence of abnormality, disease or surgery of: If yes please elaborate
1) the respiratory system? Yes No
2) the central and peripheral nervous system? Yes No
3) the genito urinary system? Yes No
4) the abdominal organs? Yes No
5) the head, face, mouth, throat, eyes, ears ,nose Yes No
and neck?
6) the skin, muscles, bones and joints? Yes No
7) The Cardiovascular system:
a) Are the peripheral pulses normal? Yes No
b) Is there any evidence of heart enlargement? Yes No
c) Are there murmurs or abnormal heart sounds? Yes No
d) Do you suspect any abnormality of the Yes No
cardiovascular system?
Declaration by the parent accompanying the child:
I hereby confirm that all facts regarding the child as recorded by the doctor are true and complete.
Signature of the parent: ______________ Name of the parent ____________________________
Doctor’s Declaration
• I hereby confirm that I have, this day, examined the above individual personally, in private and
recorded the above information in my own handwriting. I certify that I have personally recorded
the history as informed by the examinee/parent accompanying the child.
• Place of Examination: Clinic Examinee’ s Residence
• I declare that the examinee has signed/affixed his/her thumb impression in my presence.
Dated at _____________on the __________day of_________ 200 at a.m./p.m.
_______________________ ___________________________
Signature / thumb impression Signature of the Medical Examiner
of the examinee Name & Address
Qualification
Code:
Limit
__________________________________________________________________________________
Confidential Comments from Doctor
Are there any points on which you suggest further information be obtained? YES NO
• For physical investigations

• For mental level assessment
_____________________________________________________________________

Juvenile - FMR - PDF For MINOR

Uploaded by

Copyright:

Available Formats

Juvenile - FMR - PDF For MINOR

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Juvenile - FMR - PDF For MINOR

Uploaded by

Copyright:

Available Formats

LIFE INSURANCE CORPORATION OF INDIA

Zone Division Branch

Agent/D.O. Code: Introduced by: (name & signature)

Name of the child: (Master/ Miss)

A. Details of Physical Examination

For Children Below 2 yrs:

C. Immunization History: (Mandatory for ages < and equal to 5 yrs)

Declaration by the parent accompanying the child:

Signature of the parent: Name of the parent ______________

• Place of Examination: Clinic Examinee’ s Residence

Dated at ___on the day of_ 200 at a.m./p.m.

• For physical investigations

You might also like