Remolin FaceMatch Report - OS26435000
Match Score: 97.51% (Perfect match)
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ICICIPRUDENTIALMEDIGAL
LIF INSURANCE EXAMINATION
REPORT(MER)
Application No.
OS2642so0o
This report is strictly confidential Examinee Name: Mr.IMrs./Ms
& should NOT be discussed/revealed/handed SUHA D. 2.
Examination over in original or
Date:3|t
Mark Of ldentification: Place: - Clinic photocopy to anyorne.
Mole/Scar /Any Other Residence/Office
Date of Birth: (Specify location) 9 Time: 30t
0
DD 02 MM
29YYYY Gender: Male
Photo ID checked: Passport/ Female | Examinees Contact no.
Election ID / Pan Card
ID cardIAny other / Driving License / Credit Card
with photo / Recognízed
Details of photo ID checked Club carao.
Measurements:
Height: S Tcms Weight: Habits &
Addictions:
82Skgs Waist: bcms Hip:28 cms
Blood Pressure: Initial TYPE
(If>140/90, pls record
22Systolic / LO_Diastolic
QUANTITY PER DURATION
3 reading with intervals of 5 (DAYWEEKIMTH)
1 mins each) Cigaretes/Beedis/Cigar
2
Pulse rate and character: 3 Gutkha/Snuff/Paan etc
BeerWineHard Liquor
Family History &
Health Status:
2mthow 2¢om
RELATION AGEIF LIVING HEALTH STATUS
FATHER IF DECEASED, AGE AND CAUSE OF DEATH
MOTHER
BROTHER (S)
SISTER (s)
Ifanswers to any of the questions
below are "Yes", please provide details for each condition as
&date of diagnosis. 2) Name & Address of the treating doctor / hospital. 3) Duration of illness/ follows: 1) Question No; diagnosis
examinee still under treatment? 5) Nature of injury and date of recovery. 4) ls the
tests done and results.
PLEASE TICK THE RELEVANT BOXES
YES NO IF YES, DETAILS
1) Are you the examinees medical attendant? If yes, since
year(s).
2) a) Is there any abnormality or deformity or disorder in general
b) Describe Build - Normal / thin / muscular l obese /stocky
appearance?
c) Has there been any significant
weight gain or weight loss recently?
3) Whether in the past, the examinee:
a) Has been hospitalized for Accident/ Medical treatment / Surgery (If Yes, details pls)
b) Has he undergone any Path tests (Including HIV and HBSAg) /Radiological tests
Cardiological tests / USG /2 D Echo /CT scan/MRUMammogram or any other tests
(Please specify date/reason/ findings)
c) Underwent surgery, if yes, please specify:
i) The year and nature of operation & diagnosis
ii) Location of the scar, size & condition of the scar.
any
i) Degree of impairment, if If answer is yes, please
4) Has the examinee or his/ her spouse been tested positive or is under treatment provide details as per the
for HIV / AIDS /Sexually transmitted diseases (e.g. syphilis, gonorrhoea, etc.) questions mentioned above
5) Mouth, Eyes, Ears, Nose and Throat: (Kindly attach separate sheet
a) Is there any evidence of oral
cancer or leukoplakia? for details, if required)
b) Any history of ear discharge / perforation / nose bleed
or any other ear / nose /
throat abnormality
eye / retinal abnormality or
c) Any history of error of refraction or evidence of
Cataract or generalized), peripheral neuritis, fainting,
6) a) ls there any history of seizures (focal
frequent headaches?
b) Is there any evidence of paresis, paralysis,
abnormal gait, speech, wasting,
pupillary reflexes?
involuntary movements,
7) CVS: arrhythmia, peripheral vascular disease?
a) History of exertional dyspnoea, gross pallor?
gallop, carotid bruit, raised JVP. pedal edema,
b) Any evidence of extent, point of maximum
yes, please give the grade
c) Is murmur present?
If
intensity and conduction andPTCA,the probable diagnosis.
CABG, Open Heart Surgery?
d) Any history of Stenting,
<br>
PLEASE TICK THE RELEVANT BOXES
YES NO
8) a) Any hislory of breathlessness, wheezing IF YES, DETAILS
cough, bronchitis, asthma, TB?
b) Any evidence of rhonchi, rale, emphysema?
9) a) Is the examinee on treatment for
and duration cf Rx? How is the control?hypertension? f yes, mention medication
Any other risk factors?
b) Is there any evidence of end organ
damage?
10) a) ls examine suffering
from Diabetes? yes, mention
duration of Rx? How is the control? medication and
b) Is there any evidence of end organ Any other risk factors?
11) GI System - Is there:
damage?
a) Any history of hernia,
pancreas, stomach, disease of liver, gall bladder (like stones etc.).
intestines?
b) Any evidence of organomegaly in abdominal pelvis &lor presence
c) Any history of piles, fissure, of free fuid
fistula, ulcerative colitis?
d) Any history of jaundice? If yes,
any viral markers
12) GU System: done?
Has the examinee suffered or
infections etc. of is suffering from
kidney, ureter, urinary bladder or diseases like stones,
13)ls there any evidence urethra?
of Endocrine, thyroid dysfunction?
If yes,
14) Any history of arthritis please give details
I fractureljoint surgery
/ hyperuricemia If answer is yes,
/ gout? please provide
15) a) Any evidence of psoriasis, eczema, details as per the questions
b) Any operativel non varicose veins or xanthelsma? mentioned on eartier page
operative significant scars
16) Are there any abnormalities -bums, injunes.
in testes (Kindly attach separate sheet for
(Please do a physical examination relating to location, size and consistency?
only in case of suspicion) details, if required)
17) a) Is there any history
of evidence of cancer, tumor,
b) Has examinee suffered growth or cyst?
from significant enlargement
18) a) Is there any history
of lymph glands?
of anxiety / stress / depression /
b) Was the examinee treated for any psychosis.
medication given and absenteeismpsychiatric ailment? If so, give
details about
from work, if any
19) Is the examinee
currently under any form of medication?
20) FOR FEMALE EXAMINEE ONLY:
a) Any adverse menstrual history and
LMP?
b) Any history of miscarriage, abortion, MTP,
gestational HT/DM? If yes give details.
c) ls she now pregnant? If yes, number of weeks
d) Do yoususpect any disease related to
examination only in case of suspicion) breast on history? (Please doa physical
e) Any reason to suspect disease of pelvic organs on history?
Please mention you
suspicion (no need for intermal examination)
f) Has she undergone any of these tests: pap smear, mammogram or
ultrasòund
of pelvis? If yes, please give details of date, reason and result.
Important Note:- This contract of insurance is on the principle of utmost good faith,
complete details of your health, previous medicalbased which means that you have disclosed
history (if any) and any other details about yourself and your
disclose any details (health or otherwise), which have not been disclosed or have family. If you wish to
please contact any of our touch points as specified below. Please note that been incorrectly disclosed, in the proposal fom,
policy null and void. Non-disclosure of any material information may render the
EXAMINEES DECLARATION: | declare that the answers to the above questions are true, and
material information and I understand that the answers given by me to each of the questions in the that | have not withheld any
proposal and MER shall be the
basis of the contract for the assurance on my life with
IcIIPrudential Life Insurance Company Ltd.
Signature / Thumb Impression of Examinee Signature of person accompanying minor life & Relation City
EXAMINERS DECLARATION: -I hereby declare that the examinee has signed/ affixed his i her thumb impression in my presence
Dr. SANIA SABAHI
L0535O
MBBS aebali,MARS, cOMPIDOCI2019917557
StampMih M Gode ME Name and Qualification
Signature of the Medical Examiner
CONFIDENTIAL COMMENTS FROM MEDIÇAL EXAMINER:
Was the examinee co-operative? (YES / NO) or any
lifestyle or character which might unfavorably affect insurability
In your opinion, is there anything about the examinees health,
points on which you suggest further information be obtained?
- impression, suggestions, recommendations
Any other remarks e.g: your clinical
Medimate Diagnostics
Age / Gender: 35/Male Date and Time: 13th Nov 24 7:54AM
Patient ID: 240916
Patient Name: SUHAS D K
AR: 70bpm VR: 69bpm QRSD: 96ms QT: 352ms QTcB: 377.48ms PRI: 120ms P-R-T: 53° 33° NA
REPORTED BY
ECG Within Normal Limits: Sinus Rhythm, Incomplete Right Bundle Branch Block. Please correlate
clinically.
Dr Kavitha Girish
Disclaimer: Analysis in this report is based on ECG alone and should only be used as an adjunct to clinical history, symptoms and results of other invasive and non-invasive tests and must be interpreted by a qualified physician.
NAME : Mr. SUHAS D K REG / LAB NO. : 24110048 / 7595
AGE / SEX : 35 Yrs / Male DATE OF COLLECTION : 13-11-2024 at 10:07 AM
REFERRED BY : ICICI PRUDENTIAL DATE OF REPORT : 13-11-2024 at 04:11 PM
TEST PARAMETER RESULT REFERENCE RANGE
HAEMATOLOGY
COMPLETE BLOOD COUNT(CBC)
HAEMOGLOBIN 15.9 gm/dl 14 - 18 gm/dl
TOTAL COUNT 7000 cells/cumm 4000 - 11000 cells/cumm
DIFFERENTIAL COUNT
NEUTROPHILS 54 % 40 - 70 %
LYMPHOCYTES 35 % 20 - 45 %
EOSINOPHILS 06 % 2-8%
MONOCYTES 05 % 1-6%
BASOPHILS 00 % 0-1%
PLATELET COUNT 2.76 Lakhs/cumm 1.5 - 4.5 Lakhs/cumm
ESR 01 mm/hr 0 - 9 mm/hr
R.B.C COUNT 6.02 mill/cumm 4.5 - 6.2 mill/cumm
PACKED CELL VOLUME (PCV) 49.3 % 37 - 47 %
M.C.V 100.2 fl 80 - 98 fl
M.C.H 30.2 pg 26 - 34 pg
M.C.H.C 37.4 % 31 - 38 %
BIOCHEMISTRY
FASTING BLOOD SUGAR 93.6 mg/dl 60 - 110 mg/dl
Dr. Panchakshari
MBBS,MD Pathology consultant pathologist
KMC No.55607
Page 1 of 5
NAME : Mr. SUHAS D K REG / LAB NO. : 24110048 / 7595
AGE / SEX : 35 Yrs / Male DATE OF COLLECTION : 13-11-2024 at 10:07 AM
REFERRED BY : ICICI PRUDENTIAL DATE OF REPORT : 13-11-2024 at 04:11 PM
TEST PARAMETER RESULT REFERENCE RANGE
LIPID PROFILE TEST (LPT)
TOTAL CHOLESTEROL 208.4 mg/dl up to 200 mg/dl
TRIGLYCERIDES 150.4 mg/dl up to 200 mg/dl
Special condition:
Borderline high risk : 200 - 400 mg/dL
Elevated : > 400 mg/dL
HDL CHOLESTEROL - DIRECT 50.3 mg/dl 35 - 55 mg/dl
LDL CHOLESTEROL - DIRECT 128.0 mg/dl up to 150 mg/dl
VLDL CHOLESTEROL 30.1 mg/dl 0 - 60 mg/dl
TC/HDL 4.1
LDL/HDL 2.5
Dr. Panchakshari
MBBS,MD Pathology consultant pathologist
KMC No.55607
Page 2 of 5
NAME : Mr. SUHAS D K REG / LAB NO. : 24110048 / 7595
AGE / SEX : 35 Yrs / Male DATE OF COLLECTION : 13-11-2024 at 10:07 AM
REFERRED BY : ICICI PRUDENTIAL DATE OF REPORT : 13-11-2024 at 04:11 PM
TEST PARAMETER RESULT REFERENCE RANGE
LIVER FUNCTION TEST (LFT)
TOTAL BILIRUBIN 0.91 mg/dl 0 - 1 mg/dl
DIRECT BILIRUBIN 0.20 mg/dl 0 - 0.25 mg/dl
INDIRECT BILIRUBIN 0.71 mg/dl 0 - 0.75 mg/dl
TOTAL PROTEIN 6.8 g/dl 6 - 8.5 g/dl
SERUM ALBUMIN 3.9 g/dl 3.5 - 5.2 g/dl
SERUM GLOBULIN 2.9 g/dL 2.3 - 3.5 g/dL
A/G RATIO 1.3 1 - 1.5
ASPARATE AMINOTRANSFERASE (SGOT/AST) 36.8 U/L up to 40 U/L
ALANINE AMINOTRANSFERASE (SGPT/ALT) 39.2 U/L up to 40 U/L
ALKALINE PHOSPHATASE 148.9 IU/L 25 - 147 IU/L
GGT 40.2 U/L 11 - 43 U/L
HbA1c (GLYCOSYLATED Hb) 5.8 % 4-6%
MEAN BLOOD GLUCOSE 117.8 mg/dl
Degree of Control HbA1c MBG
Normal < 6.0 % 61-124 mg/dl
Good Control 6.0-7.0 % 124-156 mg/dl
Fair Control 7.0-8.0 % 158-188 mg/dl
Poor Control > 8.0 % >188 mg/dl
SERUM CREATININE 0.82 mg/dL 0.6 - 1.4 mg/dL
Dr. Panchakshari
MBBS,MD Pathology consultant pathologist
KMC No.55607
Page 3 of 5
NAME : Mr. SUHAS D K REG / LAB NO. : 24110048 / 7595
AGE / SEX : 35 Yrs / Male DATE OF COLLECTION : 13-11-2024 at 10:07 AM
REFERRED BY : ICICI PRUDENTIAL DATE OF REPORT : 13-11-2024 at 04:11 PM
TEST PARAMETER RESULT REFERENCE RANGE
SEROLOGY
HBsAg NEGATIVE
CARD TEST
HIV I & II NON-REACTIVE
CLINICAL PATHOLOGY
URINE NICOTINE NEGATIVE
Dr. Panchakshari
MBBS,MD Pathology consultant pathologist
KMC No.55607
Page 4 of 5
NAME : Mr. SUHAS D K REG / LAB NO. : 24110048 / 7595
AGE / SEX : 35 Yrs / Male DATE OF COLLECTION : 13-11-2024 at 10:07 AM
REFERRED BY : ICICI PRUDENTIAL DATE OF REPORT : 13-11-2024 at 04:11 PM
TEST PARAMETER RESULT REFERENCE RANGE
COMPLETE URINE ANALYSIS
PHYSICAL CHARACTERS
COLOUR PALE YELLOW
APPEARANCE CLEAR
SPECIFIC GRAVITY 1.020
pH 6.5
CHEMICAL CONSTITUENTS
ALBUMIN ABSENT
SUGAR ABSENT
BILE SALTS ABSENT
BILE PIGMENTS ABSENT
KETONE BODIES ABSENT
MICROSCOPY
PUS CELLS 1 - 2 /hpf
R.B.C ABSENT /hpf
EPITHELIAL CELLS 3 - 4 /hpf
CASTS ABSENT
CRYSTALS ABSENT
OTHERS ABSENT
Dispatched by: Megha C **** End of Report **** Printed by: Megha C on 13-11-2024 at 07:11 PM
Dr. Panchakshari
MBBS,MD Pathology consultant pathologist
KMC No.55607
Page 5 of 5
