AIA Singapore Private Limited (REG.No.201106386R) 3 Tampines Grande #09-01, Singapore 528799
MEDICAL SPECIALIST REPORT 1. Stroke 2. Brain aneurysm 3. Cerebral shunt insertion 4. Carotid artery surgery SECTION 1 – PATIENT’S PARTICULARS (To be completed by policy owner) Life Assured’s Full Name: (Patient) Life Assured's NRIC/Passport No./FIN No:
(Patient) Policy Number: MEDICAL SPECIALIST REPORT (To be completed by the patient’s specialist) SECTION 2 – SPECIALIST’S PARTICULARS
Name of Specialist: MCR No:
Field of Specialty:
Name of Medical Institution:
Please tick the appropriate box for medical condition(s) applicable for Sections to be completed the patient
Stroke Sections 3, 4, 8 and 9 Brain aneurysm Sections 3, 5, 8 and 9 Cerebral shunt insertion Sections 3, 6, 8 and 9 Carotid artery surgery Sections 3, 7, 8 and 9
SECTION 3 – DETAILS OF DISEASE
1. Please provide the final and full diagnosis of the patient’s medical condition.
2. When did the patient first consulted a doctor for the medical condition referred to in question (1)? Date of first consultation: ____dd/____mm/______yyyy
Signature of Medical Specialist:
*L4MEDRT* Page 1 of 10
L4MEDRT (08/2020) L4MEDRT (08/2020) *L4MEDRT*
Patient’s NRIC/Passport No./FIN No:
Name of patient:
3. What symptoms were present during the first consultation for the medical condition referred to in question (1)?
If date is unknown, please provide the Symptoms present during Date patient first experienced duration that the symptoms have consultation date in the symptoms lasted prior to consultation date in question (2) question (2). Please circle duration in days, months or years.
____dd/____mm/______yyyy Duration: _____ (days/months/years)
____dd/____mm/______yyyy Duration: _____ (days/months/years)
4. When was the diagnosis mentioned in question (1) first established? Date of first diagnosis: ____dd/____mm/______yyyy
5. Please provide the date when the patient or next of kin was first informed of the diagnosis mentioned in question (1): ____dd/____mm/______yyyy
6. Was the diagnosis mentioned in question (1) a congenital disease? YES NO If “YES” please answer questions (6a) and (6b). If “NO” please proceed to question (7).
6a. Date of first appearance (or first detection) of the congenital disease relevant to the diagnosis mentioned in question (1): ____dd/____mm/______yyyy
6b. Please provide details of the congenital disease that appeared or was detected on the date mentioned on question (6a).
Signature of Medical Specialist:
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Patient’s NRIC/Passport No./FIN No:
Name of patient:
7. Was the diagnosis mentioned in question (1) a complication of a congenital disease? YES NO If “YES” please answer questions (7a) to (7e).
7a. Please provide the diagnosis of the congenital disease that resulted in the disease mentioned in question (1).
7b. Please provide the date of first diagnosis as identified in question (7a): ____dd/____mm/______yyyy
7c. Please provide the date when the patient or next of kin was first informed of the diagnosis mentioned in question (7a): ____dd/____mm/______yyyy
7d. Please provide the date of first appearance (or first detection) of the diagnosis mentioned in question (7a): ____dd/____mm/______yyyy
7e. Please provide details of the congenital disease that appeared (or was detected) on the date mentioned on question (7d):
8. Please provide the name and full address of the doctor who referred the patient to you.
Name of doctor Full address
Signature of Medical Specialist:
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Patient’s NRIC/Passport No./FIN No:
Name of patient:
SECTION 4 – STROKE
9. Nature of the episode.
Had the patient suffered from an infarction of brain tissue (stroke)? 9a. YES NO If “YES” please complete questions (10) to (16). Had the patient suffered from a cerebral and/or subarachnoid hemorrhage 9b. YES NO (stroke)? If “YES” please complete questions (10) to (16).
9c. Had the patient suffered from a transient ischemic attack? YES NO
9d. Had the patient suffered from a brain damage due to an accident or injury? YES NO
9e. Had the patient suffered from a brain damage due to vasculitis? YES NO
9f. Had the patient suffered from a brain damage due to infection? YES NO
9g. Had the patient suffered from a brain damage due to an inflammatory disease? YES NO
9h. Had the patient suffered from a vascular disease affecting the eye or optic YES NO nerve?
9i. Had the patient suffered from an ischemic disorder of the vestibular system? YES NO
Had the patient suffered from a secondary haemorrhage within a pre-existing 9j. YES NO cerebral lesion? 9k. If “NO” is answer for all questions (9a to 9j), please provide details of the nature of the episode.
Signature of Medical Specialist:
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Patient’s NRIC/Passport No./FIN No:
Name of patient:
10. Was there any evidence of infarction of brain tissue (due to intracerebral embolism or cerebral thrombosis), cerebral hemorrhage or subarachnoid hemorrhage on CT, MRI or other reliable imaging techniques? YES NO
10a. If “YES” please provide details on the result of the imaging technique(s). Name of Date of imaging Description of infarction of brain tissue, cerebral and/or imaging technique(s) subarachnoid hemorrhage on imaging technique(s) technique(s) (dd/mm/yyyy)
10b. If “NO” please advise the clinical basis of diagnosis of infarction of brain tissue, cerebral and/or
subarachnoid hemorrhage.
11. Was there evidence of permanent neurological damage (i.e. brain tissue damage) due to stroke? YES NO If “YES” please provide further details of the permanent neurological damage (i.e. brain tissue damage).
12. Date of patient’s latest review/consultation for stroke at your clinic/hospital: ____dd/____mm/______yyyy
Signature of Medical Specialist:
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Patient’s NRIC/Passport No./FIN No:
Name of patient:
13. Was there any neurological deficit due to stroke presented during the last review/consultation on the date mentioned in question (12)? YES NO If “YES” please answer questions (13a) to (13c). 13a. Please provide details of the neurological deficit(s) present during the latest medical
review mentioned in question (12). 13b. How long has the neurological deficit lasted Duration: ______weeks from the date of the stroke? 13c. Was the neurological deficit permanent? YES NO
14. Based on the latest medical review on the date mentioned in question (12), please provide details on the patient’s ability to perform the following activities of daily living (ADL).
Activities of daily living (ADL) Ability to perform ADL during last consultation
Washing – wash in the bath or shower (including 14a. Has the patient suffered from a getting into and out of the bath or shower) or wash permanent inability to perform washing? satisfactorily by other means. YES NO
Dressing – put on, take off, secure and unfasten all 14b. Has the patient suffered from a garments and as appropriate, any braces, artificial permanent inability to perform dressing? limbs or other surgical appliances. YES NO 14c. Has the patient suffered from a Transferring – move from a bed to an upright chair permanent inability to perform or wheelchair and vice versa. transferring? YES NO 14d. Has the patient suffered from a Mobility – move indoors from room to room or level permanent inability to perform mobility? surfaces. YES NO
Toileting – use the lavatory or otherwise manage 14e. Has the patient suffered from a bowel and bladder functions so as to maintain a permanent inability to perform toileting? satisfactory level of personal hygiene. YES NO
14f. Has the patient suffered from a Feeding – feed oneself once food has been prepared permanent inability to perform feeding? and made available. YES NO
Signature of Medical Specialist:
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Patient’s NRIC/Passport No./FIN No:
Name of patient:
15. If “YES” is the answer for any part of question (14), please answer questions (15a) and (15b).
15a. Duration of inability to perform activities of daily living as mentioned in question (14): ______(days/weeks/months) 15b. Please provide details on the permanent neurological deficit that resulted in the permanent inability to perform activities of daily living as mentioned in question (14).
16. Date of next scheduled review/consultation: ____dd/____mm/______yyyy
SECTION 5 – BRAIN ANEURYSM SURGERY
17. Had the patient undergone surgery to repair an intracranial aneurysm or removal of an arteriovenous malformation? YES NO If “YES” please answer questions (17a) to (17d).
17a. Please state the date of surgery: ____dd/____mm/______yyyy 17b. Was any endovascular surgery carried out? YES NO 17c. Was any craniotomy surgery carried out? YES NO 17d. If “NO” is the answer for questions (17b) and (17c), please state the type of surgery performed:
SECTION 6 - CEREBRAL SHUNT INSERTION
18. Had the patient undergone a surgical shunt insertion from the ventricles of the brain in order to relieve raised pressure of the cerebrospinal fluid? YES NO If “YES” please advise the date of surgical shunt insertion: ____dd/____mm/______yyyy
Signature of Medical Specialist:
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Patient’s NRIC/Passport No./FIN No:
Name of patient:
SECTION 7 – CAROTID ARTERY SURGERY 19. Was there narrowing / stenosis of the carotid artery? YES NO If “YES” please answer questions (19a) and (19b). 19a. Please provide the date and results of the diagnostic test used to detect carotid artery stenosis?
19b. Percentage of stenosis of carotid artery: ______% 20. Had the patient undergone surgical endarterectomy of the carotid artery? YES NO If “YES” please answer questions (20a) and (20b). 20a. Was endarterectomy of the carotid artery performed via an open surgery? YES NO 20b. Was endarterectomy of the carotid artery performed via a percutaneous YES NO carotid angioplasty?
SECTION 8 – OTHER DISEASES 21. Was the patient’s medical condition in the presence of a HIV infection? YES NO If “YES” please provide the information for (21a) and (12b).
21a. Date of first diagnosis of HIV infection: ____dd/____mm/______yyyy
21b. Date the patient or next of kin was informed of the diagnosis of HIV infection: ____dd/____mm/______yyyy 22. Has the patient been diagnosed with or treated for other chronic medical condition(s)? YES NO If “YES” please complete the table below. Name and address of doctor Diagnosis Date of diagnosis consulted
____dd/____mm/______yyyy
____dd/____mm/______yyyy
____dd/____mm/______yyyy
Signature of Medical Specialist:
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Patient’s NRIC/Passport No./FIN No: Name of patient:
23. Will you agree and authorize us to release this medical information if such disclosure is required by the Financial Industry Disputes Resolution Centre Ltd (FIDReC) of Singapore or any proper Government Authority? YES NO
I hereby declare that the foregoing answers to each and all are true and to the best of my knowledge and belief.
Name and Signature of the Medical Specialist: Date: ____dd/____mm/______yyyy
Practice Stamp of the Medical Specialist
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Patient’s NRIC/Passport No./FIN No:
Name of patient:
SECTION 9 – COPY OF MEDICAL DOCUMENTS
Please attach the following reports where applicable:
1. Stroke: CT-Brain / MRI brain used to investigate for stroke Report of procedure/surgery performed for the treatment of stroke (if available) Referral letter (if there is any) 2. Brain aneurysm: CT-Brain, MRI brain, and/or CT-angiogram used to investigate for brain aneurysm Report of procedure/surgery performed to repair the intracranial aneurysm or remove the arteriovenous malformation Referral letter (if there is any) 3. Cerebral shunt insertion: CT-Brain and/or MRI brain used to investigate for the disease that required a cerebral shunt insertion Report of procedure/surgery of cerebral shunt insertion Referral letter (if there is any) 4. Carotid artery surgery: Carotid arteriography, ultrasonography, CT and/or MRI used to investigate for carotid artery stenosis Report of surgical carotid endarterectomy Referral letter (if there is any)
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