Medical Application Form (Page 2 of 4) in pdf

Please tick relevant box if you have ever been diagnosed with and/or received any treatment/felt any

disorder/pain/had any other symptoms:

*Examples mentioned below are only descriptive and are not meant to limit aforementioned medical conditions.

(Please tick relevant box)

1. Infectious and parasitic diseases (e.g. Typhoid, Enteritis, Tuberculosis, Malaria

11. Pregnancy, complications of pregnancy, child birth and the

....)*

puerperium incl. abortions

2.Neoplasms/Cancer (benign or malignant)*

12. Disease of the skin and subcutaneous tissue ( Abscess , ulcer , cellulitis ,

cysts , dermatitis , eczema , herpes , corn , pigmentation or melanoma ...

3. Diseases of the

13. Diseases of the musculoskeletal system and

Connective tissue ( Myalgia or Body pain , arthropathy , joint stiffness or

Endocrine system (Pituitary, Thyroid disorders, Poly cystic Ovaries,

•

Diabetes .....)*

dislocation , Lumbago , Sciatica , Inter vertebral Disc disorders, Scoliosis

or any acquired bone deformity….

Nutritional ( Vitamin Deficiency , Anaemia , Rickets ...)

•

metabolic diseases ( Glucose intolerance , Lipid disorders , Gout ...)

•

immunity disorders

•

4. Diseases of blood and blood forming organs (All types of Anaemia,

14. Congenital anomalies (cardiovascular anomalies, Cleft lip or plate and

Coagulation defects such as Haemophilia or Sickle cell, Thrombocytopenia,)

hereditary/genetic diseases (Down syndrome...)

5. Mental-/psychiatric disorders (Anxiety, Depression, Insomnia, Schizophrenia,

15. Certain conditions originating in the perinatal period (e.g. Maternity

Mental retardation...)

hypertension – Cervical incompetence, Premature rupture of membrane .....)

6. Diseases of the ,

16. Diseases of genitourinary system ( cystitis or Urinary bladder disorders ,

male testicular disorders , Variocele , female ovarian or uterine disorders ,

nervous system

•

female cervical , vaginal or vulval disorders , Salpingitis or PID , .....)

(Cerebral haemorrhage, Thrombosis, Seizure, Bell’s palsy, Parkinsonism,

•

Multiple sclerosis, Pituitary adenoma, meningitis ....)

kidney diseases ( Renal colic or stone , Renal failure , nephritis or nephrotic

sense organs

•

syndrome )

ears ( Ear infection , wax , surgery of tympanic

membrane , ortho

And breast disorders (Abscess, cyst, neoplasm or any mass, nipple discharge

sclerosis or hearing impairment ...)

or disorder, Pain or hypertrophy ....)

Eyes (Conjunctivitis, Glaucoma, Cataract, other Retinal or lens disorders, Visual

disturbance or blindness ....)

Nose (Rhinitis, Sinusitis, nasal allergy, nasal polyp, epistaxis ....)

7. Diseases of the cardiovascular system (Hypertension, Ischemic and Coronary

17. Previous medical/surgical hospitalisations, procedures

heart disease, Myocarditis, Arrhythmia, Valve disorders, ventricular hypertrophy or

and operations

cardiomyopathy .....)

8. Diseases of the respiratory system( Bronchitis , Pneumonia , Upper respiratory

18. Any (chronic) disease(s), symptoms and complaints not

mentioned above

tract infections , allergy , Asthma , Respiratory distress , Lung fibrosis , pulmonary

embolism ....)

ORIENT INSURANCE PJSC

P.O. Box 27966, Dubai – UAE

Tel.: +971 4 253 1300 Fax: +971 4 251 5079

Medical Application Form Page 2

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