Apollo at allo HealthAssure HEALTHAREURANCE Péssond-Infacmation [Tull Mame-ofthe Applicant: Kamala. Pandas pple ation.No.. elephone/M obile:no. ender, e of Bil eight (cr) eial alicallone ‘Occupation: Houseryife. (Calling Crate, O04 October ZO7TS ‘Medical History “Sr No. ‘Question ‘YesiNo Details 1 igh Blood Sugal-{ Diabetes We. i igh Blood Pressures High Na folesteral eat Problem or heart Sager, like arcidplasty, bypass, a pacemaker, hole jf heart tr. had. 3 lany.chest-pait, brédthlessness, Ne ainting attacks or any-other Batt dishase [tyroid disorder JPiuitary 4 disorder or any other endocrine No disease a roke [Paralysis] Head mjury. No 6 pilepsy Fits] Mental No Hiserders iva] Respiratory disease F 7 Oe Prato Ne fiver etawjach /,gall bladder Diseases s Pitess Fissure / Fistula, Hernia-operated # Hanned surgery, IKidnevand Urinary tract IDiseases ineluding-stone 10 (Cancer? Tumor] Mass Lump? Na Cyst 'growth. anywhere in bod 7 No" Osteoarthritis 7 Rheumatoid [Arthritis / any: other Bone or Joint disorders / Knee disorder / Ligament tear / Fractures. No 12 far, Nose, Throat, Eye |disorders / cataract, ear |discharge, hearing loss, lecrease in vision except Tce! glasses No 13 |HIV7AlDs / Immune system No 15 [Any other disease that you or lany other member has and you ould like to disclose? No, 16 fave you underwent any lprotong consultation or investigation or ever hospitalized and / or advised for lany treatment / Surgery? No 7 In the last 2 years have you consulted any physician or have! faken over the counter drugs for| lany signs and symptoms. No 18 19 [Do you take any regular Imedicine? is there any medical / surgical history you want us to know and| record? No No }o you Consume AICONOT , [smoke cigarettes or chew jobacco? No 2 lease provide your pregnancy tetails, tan 2FTND 2 is there any history ‘Of Breast [disorders including lump / Fibroid uterus / Fibroadenoma / irregular period / cyst or any surgery? No ‘ortability Case No 33 7 Final Remark any No Adversity