PCS - Physician's Clinical Statement Form 2019 Etiqa

PHYSCIAN’S CLINICAL STATEMENT FORM
MEDICAL OPERATIONS DIVISION (MOD)

HOTLINE: (63 2) 8895-3308 / TOLL FREE: 1-800-10-8895-3308 / EMAIL: [email protected]; [email protected]
This is to certify that I have attended to the medical needs of Mr./Mrs./Ms. __________________________________________________, ________ years old,
________ (gender), presently residing at _______________________________________________________________, last
_________________________________ (inclusive dates of consult), at ____________________________________________________________________
(hospital/clinic name). The impression and medical diagnosis is
____________________________________________________________________________________________________. Diagnostic procedure(s) done/to be
done: ___________________________________________________________________________________________________. As requested by
_________________________________________, I hereby truthfully and voluntarily state the succeeding information: (when applicable)
1. As to etiology/primary cause of above condition: Please give a brief history of the above condition:______________________________ a. Psychological in
nature: YES NO _______________________________________________________________________ b. Sexually transmitted: YES NO
_______________________________________________________________________ c. Maternity related: YES NO
_______________________________________________________________________ d. Infertility related: YES NO
_______________________________________________________________________ e. Congenital in nature: YES NO
____________________________________________________________________________ f. Chronic condition: YES NO
_______________________________________________________________________ g. For seizure disorder, secondary to alcohol or drug abuse:
YES NO
h. Related to previous admission/conditions/diseases/illnesses: YES NO
i. Inter-related or complications: YES NO
j. Dental pathology in nature: YES NO
k. Surgical Procedure – aesthetic and reconstructive in nature: YES NO
If all the answers are NO, what do you think is the etiology/primary cause of the above condition? ______________________________________________ 2. For
conditions/diseases not generally admissible:
Reason for admission:
___________________________________________________________________________________________________ 3. Primary Diagnosis and its Purpose
for a Supplemental/Replacement Therapy: _______________________________________________________________ 4. For Liver Disease: Is it alcohol
related? YES NO
5. For OB-Gyne cases: Are there plans of conception? YES NO
6. As to diagnostic procedure requested, what is the contemplated procedure? _______________________________________________________________
Relationship/reason for request:____________________________________________________________________________________________________ a. Is the
procedure conventional? YES NO
b. Or a new modality of treatment? YES NO
7. For prescribed medications: Is it a supplement? YES NO
8. For dermatological conditions:
a. Aesthetic purpose? YES NO If no, clinical indication: ____________________________________________________________ b. Wart
removal? YES NO # of areas involved _____ # of lesions _____ Pattern of spread _____ Characteristics_______________ c. Is the prescribed
medicine a skin protective? YES NO If no, clinical indication: ________________________________________ d. For Varicose Veins: Please
indicate the veins involved:_____________________________________________________________________
Is the patient symptomatic? YES NO If YES, please indicate symptom/s: ________________________________________ 9. For
Hepatitis B infection:
Mode of transmission:
_______________________________________________________________________________________________________ 10. For prescribed physical
therapy (initial session)
Indicate procedures done:
____________________________________________________________________________________________________ 11. For Medico-Legal Cases:
Nature of Incident (NOI): _______________________________ Time of Incident (TOI): _______________________________ Date of Incident
(DOI): _______________________________ Place of Incident (POI): _______________________________ Was patient under the influence of
alcohol or any substance upon examination? YES NO
Other than alcohol, what is the substance? ______________________________________________________________________________________
This statement is being issued to Etiqa Life and General Assurance Philippines, Inc. for whatever purpose it may serve them.
_______________________________________________________, M. D. Specialty/Subspecialty: ____________________________________________ (Signature
over printed name / date signed)
License number: ______________________________

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PHYSCIAN’S CLINICAL STATEMENT FORM

MEDICAL OPERATIONS DIVISION (MOD)

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