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CI-09 - Terminal Illness (Penyakit Terminal)

This medical report provides information about a patient's terminal illness diagnosis. (1) The patient was diagnosed on [date] with a terminal illness that was determined to be incurable and unable to be adequately treated. (2) The patient's life expectancy is [number] months. (3) The patient is currently receiving palliative care and medication to treat their terminal condition.

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152 views

CI-09 - Terminal Illness (Penyakit Terminal)

This medical report provides information about a patient's terminal illness diagnosis. (1) The patient was diagnosed on [date] with a terminal illness that was determined to be incurable and unable to be adequately treated. (2) The patient's life expectancy is [number] months. (3) The patient is currently receiving palliative care and medication to treat their terminal condition.

Uploaded by

nur'afeefa binti hamdan
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CI-09 DOCTOR’S STATEMENT - CRITICAL ILLNESS - TERMINAL ILLNESS

MEDICAL REPORT TO BE COMPLETED BY THE ATTENDING PHYSICIAN/ SPECIALIST CI-09


Name of Patient (Person Covered) New NRIC No.

- -
TERMINAL ILLNESS

1. What is the diagnosis? 1.


Please describe the full and exact diagnosis of the
condition causing patient to be terminally ill.

(a) Date of diagnosis: (a)


/ / (dd/mm/yyyy)

(b) Date when patient / patient’s next of kin was (b)


informed that the illness was terminal: / / (dd/mm/yyyy)

2. How long is the life expectancy of the patient? 2. months

(a) Is the patient's condition incurable and cannot be (a) Yes No


adequately treated to recover?

(b) If Yes, please provide your basis. (b)

3. What treatment is the patient currently receiving? 3. Transplant


Please tick which is applicable.
Date of transplant
/ / (dd/mm/yyyy)

Chemotherapy/Radiotherapy
Physiotherapy
Palliative care
Medication(s)
Please list down all medication prescribed to the patient now.

DECLARATION: TO BE COMPLETED BY THE ATTENDING PHYSICIAN/ SPECIALIST

I, the undersigned, certify that I have examined the above Person Covered and all statement made and answers given are true and to the
best of my knowledge and belief.

Name:

Address:

Signature and Official Stamp Date: / / (dd/mm/yyyy)

CLM-B40DSCI09-V00-022020-TAKAFUL

Great Eastern Takaful Berhad 201001032332 (916257-H)


Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur
Page 1 of 1 8793633065
mySalam CareLine: 1-300-888-938 E-mail: [email protected]
mySalam Portal: www.mysalam.com.my

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