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| 1 | +# PART 3. CURRENT VITALS. COMPLETE FOR PARAMEDICALS AND MEDICALS. MUST BE COMPLETED BY THE NURSE OR THE EXAMINING PHYSICIAN (i.e., Cardiologist, Internist, or General Practitioner) |
| 2 | + |
| 3 | + |
| 4 | + |
| 5 | +| | | | |
| 6 | +|------------------------------------------|------------------------------------------|----------------------------| |
| 7 | +| Family Name/Last Name of Person Examined | Given Name/First Name of Person Examined | Date of Birth (dd/mm/yyyy) | |
| 8 | +| Blondeau | Vincent | 27/9/84 | |
| 9 | + |
| 10 | + |
| 11 | + |
| 12 | + |
| 13 | + |
| 14 | +| | | | |
| 15 | +|----------------------------------------------------------------------------------------------------------------------|---------|--------| |
| 16 | +| 1. Of the oral cavity, eyes, ears, nose, throat, skin (including xanthelasma, xanthomata, arcus senilis)? | Yes [ ] | No [ ] | |
| 17 | +| 2. Of the lymph nodes or the thyroid gland? | Yes [ ] | No [ ] | |
| 18 | +| 3. Of chest, spine or extremities? | Yes [ ] | No [ ] | |
| 19 | +| 4. Of lungs on percussion and auscultation? | Yes [ ] | No [ ] | |
| 20 | +| Please circle each condition where there is a positive response and report the details of such conditions on page 9. | | | |
| 21 | +| Are any murmurs present? | Yes [ ] | No [ ] | |
| 22 | + |
| 23 | + |
| 24 | + |
| 25 | +A. Height |
| 26 | +m / |
| 27 | +cm 64 |
| 28 | +Weight 75 |
| 29 | +kg |
| 30 | +BMI |
| 31 | + Did Proposed Insured's weight change over the past 12 months? |
| 32 | +Yes [ ] |
| 33 | +No [ ] |
| 34 | + |
| 35 | +If "Yes," please provide details: |
| 36 | + |
| 37 | +Loss of |
| 38 | +Gain of |
| 39 | +kilograms |
| 40 | + |
| 41 | +B. |
| 42 | +Pulse |
| 43 | +per minute |
| 44 | +Regular |
| 45 | +Yes [ ] |
| 46 | +No [ ] |
| 47 | + |
| 48 | +If irregular, type of irregularity: |
| 49 | + |
| 50 | +If extra systoles, please state number per minute: |
| 51 | + |
| 52 | +C. Blood pressure (seated) 120 84 |
| 53 | +2nd 130 / 75 |
| 54 | + D. Urinalysis (Complete only if age 18 or older. Please fill in blanks or attach results and forward with this form) |
| 55 | + |
| 56 | +Protein |
| 57 | +Sugar |
| 58 | +Blood |
| 59 | + |
| 60 | +Date of last menses |
| 61 | + |
| 62 | +For Paramedicals only: Skip to Part 6. |
| 63 | + |
| 64 | +PART 4. CURRENT HEALTH STATUS. COMPLETE FOR MEDICALS ONLY. MUST BE COMPLETED BY THE EXAMINING PHYSICIAN |
| 65 | + (i.e., Cardiologist, Internist, or General Practitioner) |
| 66 | + |
| 67 | +A. Is there any abnormality: |
| 68 | + |
| 69 | + |
| 70 | + |
| 71 | +B. |
| 72 | + |
| 73 | + If "Yes," complete the following: |
| 74 | + Describe below the location of transmission, if any, and your diagnostic impression: |
| 75 | + 1. Location: |
| 76 | +apex [ ] |
| 77 | +base [ ] |
| 78 | +intercostal space [ ] |
| 79 | +right of sternum [ ] |
| 80 | +left of sternum [ ] |
| 81 | + Intensity: |
| 82 | +Gr I [ ] |
| 83 | +Gr Il [ ] |
| 84 | +Gr III [ ] |
| 85 | +Gr IV [ ] |
| 86 | +Gr V [ ] |
| 87 | +Gr VI [ ] |
| 88 | + Timing: |
| 89 | +systolic |
| 90 | +diastolic |
| 91 | + Classification: |
| 92 | +organic |
| 93 | +physiologic |
| 94 | + 2. Complete if more than one murmur: |
| 95 | + |
| 96 | +Location: |
| 97 | +apex [ ] |
| 98 | +base [ ] |
| 99 | +intercostal space [ ] |
| 100 | +right of sternum [ ] |
| 101 | +left of sternum [ ] |
| 102 | + Intensity: |
| 103 | +Gr I [ ] |
| 104 | +Gr II [ ] |
| 105 | +Gr III [ ] |
| 106 | +Gr IV [ ] |
| 107 | +Gr V [ ] |
| 108 | +Gr VI [ ] |
| 109 | + Timing: |
| 110 | +systolic |
| 111 | +diastolic |
| 112 | + Classification: |
| 113 | +organic |
| 114 | +physiologic |
| 115 | + C. Is there: |
| 116 | + |
| 117 | + |
| 118 | + |
| 119 | +For "Yes" answers, please provide details on page 9. |
| 120 | + |
| 121 | + |
| 122 | + |
| 123 | + |
| 124 | +| | | |
| 125 | +|------------------------------------------------------------------------------------------------------------|----------------| |
| 126 | +| 1. Intra-abdominal abnormality? | Yes [ ] No [ ] | |
| 127 | +| 2. Any surgical scars? | Yes [ ] No [ ] | |
| 128 | +| 3. A hernia? If "Yes," describe: | Yes [ ] No [ ] | |
| 129 | +| 4. Abnormality of the central nervous system (muscular power, reflexes, etc.)? | Yes [ ] No [ ] | |
| 130 | +| 5. Oedema of the ankles? | Yes [ ] No [ ] | |
| 131 | +| 6. Inequality or inadequacy of the pulsations of the femoral, dorsalis pedis or posterior tibial arteries? | Yes [ ] No [ ] | |
| 132 | + |
| 133 | + |
| 134 | + |
| 135 | +[SIGNATURE] |
| 136 | + |
| 137 | + |
| 138 | + |
| 139 | +Page 8 of 11 |
| 140 | + |
| 141 | + |
| 142 | +IONP-7001 0124 En |
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