Insurance Medical Physical Examination Form
Personal Information
Full Name
Date of Birth
Gender
Contact Number
Address
Policy Number
Medical History
Have you had any major illnesses or surgeries?
Are you currently taking any medications?
Do you have any allergies?
Family medical history (if any):
Physical Examination
Height (cm)
Weight (kg)
Blood Pressure (mmHg)
Heart Rate (bpm)
Temperature (°C)
General Appearance
Findings (Head, Eyes, Ears, Nose, Throat)
Chest / Lungs Examination
Cardiovascular Examination
Abdomen Examination
Musculoskeletal System
Nervous System
Other Findings
Examiner's Details
Examiner Name
Medical Registration Number
Date of Examination
Remarks / Recommendations
Signature