ATTENDING PHYSICIAN S STATEMENT CRITICAL ILLNESS (SYSTEMIC LUPUS ERYTHEMATOSUS WITH LUPUS NEPHRITIS)
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- Regina Gordon
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1 ATTENDING PHYSICIAN S STATEMENT CRITICAL ILLNESS (SYSTEMIC LUPUS ERYTHEMATOSUS WITH LUPUS NEPHRITIS) Name NRIC Number Policy Number Claim Number The abovenamed is insured with us against the happening of certain contingent events associated with his/her health. A claim has been submitted in connection with SYSTEMIC LUPUS ERYTHEMATOSUS WITH LUPUS NEPHRITIS. To enable us to assess the claim, we would be grateful for your co-operation in the completion of this form. A. GENERAL INFORMATION 1. Are you the patient's usual medical doctor? If yes, over what period do your records extend to? Start date End date 2. When did the patient first consult you for this condition? 3. Please state symptoms presented and date symptoms first appeared. Symptoms Presented at First Consultation Date Symptoms First Started (DD/MM/YYYY) What / who is the source of this information? 4. In your opinion, what were the likely durations of the patient s symptoms? Please provide reasons. 5. Did the patient consult any other doctors for these symptoms before he/she consulted you? If yes, please provide details below. Name of Doctor Name of Clinic / Hospital and Address Manulife (Singapore) Pte Ltd. Reg D Page 1 of 5 SLE with Lupus Nephritis APS (1214)
2 B. DETAILS OF CRITICAL ILLNESS 6. (a) What is the diagnosis? Please describe the full details of the diagnosis. (b) Date of diagnosis / / (c) Please provide the name and address of doctor and clinic/hospital where the diagnosis was first made. (d) Date when patient was first made aware of the diagnosis 7. Please describe the exact details of the patient s condition leading to cardiac and/or central nervous system involvement. 8. Please describe the exact details of the patient s condition leading to involvement of kidneys. 9. Was renal biopsy performed to confirm diagnosis? Please give details. 10. What is the WHO classification of the Lupus Nephritis? Manulife (Singapore) Pte Ltd. Reg D Page 2 of 5 SLE with Lupus Nephritis APS (1214)
3 11. Is the diagnosis Discoid Lupus? 12. What is the prognosis? 13. Please provide full details of current treatment provided. 14. Please provide details of all investigations/test performed and attach copies of results of any investigations performed, e.g., resting ECGs, ultrasound, surgical reports, X-rays, CT scans, and any other imaging studies, laboratory evidence etc. and other relevant hospital reports. 15. Please provide the names and addresses of all clinics/hospitals to which the patient has been referred to or attended for this condition together with the names of the doctors consulted. C. MEDICAL HISTORY 16. Has the patient previously suffered from the condition specified above or any possible related illnesses? If yes, please give dates of consultations, the resulting diagnosis, the name and address of attending doctor and source of information. Manulife (Singapore) Pte Ltd. Reg D Page 3 of 5 SLE with Lupus Nephritis APS (1214)
4 17. Is there anything in the patient s medical history which would have increased the risk of Systemic Lupus Erythematosus with Lupus Nephritis? If yes, please provide full details including the date of diagnosis, name and address of attending doctor and source of information. 18. Please give details of the patient's family history which would have increased the risk of Systemic Lupus Erythematosus with Lupus Nephritis (including the relationship, nature of illness, date of diagnosis and source of information). 19. Please give details of the patient s habits in relation to past and present smoking, including the duration of smoking habits, number of cigarettes smoked per day and source of this information. 20. Please give details of the patient s habits in relation to alcohol consumption, including the amount of alcohol consumption per day and source of this information. 21. Does the patient have or ever had any other significant health condition(s)? If yes, please provide details of the condition, including diagnosis, date of diagnosis, duration of condition(s) and treatment received. Manulife (Singapore) Pte Ltd. Reg D Page 4 of 5 SLE with Lupus Nephritis APS (1214)
5 D. ADDITIONAL INFORMATION 22. Please provide us with any other additional information that will enable the Company to assess this claim. Signature of Doctor Date Address & Official Stamp Name and Qualification (printed) Manulife (Singapore) Pte Ltd. Reg D Page 5 of 5 SLE with Lupus Nephritis APS (1214)
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