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TAKAFUL IKHLAS FAMILY BERHAD
Registration No. 200201025412 (593075-U)
IKHLAS Point, Tower 11A, Avenue 5, Bangsar South,
No. 8, Jalan Kerinchi, 59200 Kuala Lumpur
Tel : 03-2723 9999 Fax : 03-2
Fax : 03-2723 9998
(Licensed under Islamic Financial Services Act 2013 and regulated by Bank Negara Malaysia)
Peringatan / Reminders
1 Borang ini hendaklah diisi oleh Pegawai Perubatan bertauliah yang memberi rawatan kepada pesakit berkenaan
This form must be completed by the certified Medical Officer who had treated the patient
2 Segala perbelanjaan untuk mendapatkan laporan ini adalah menjadi tanggungan pesakit.
Any cost incurred in relation to this report is to be borne by the patient.
NO. SIJIL / CERTIFICATE NO.
A.
MAKLUMAT PERIBADI PESAKIT / PATIENT'S PERSONAL DETAILS
1 a. Nama Pesakit/ Name of Patient :
b. No. Kad Pengenalan: Baru: Lama:
NRIC No.: New: Old:
d. Umur: e. Jantina : Lelaki Perempuan
Age: Sex : Male Female
B.
BUTIR-BUTIR PERUBATAN / TREATMENT DETAILS
1 a. (i) Pemeriksaan kesakitan / kecederaan.
Diagnosis of illness / injury.
(ii)
Please explain in detail regarding the patient's illness.
b. (i)
First date where patient was diagnosed with the illness.
(ii)
c. (i)
Berapa lamakah keadaan ini telah wujud? (
dd/mm/yyyy)
How long has this condition existed? (dd/mm/yyyy)
(ii)
Bila peserta mula mengetahui tentang penyakit ini? (dd/mm/yyyy)
When did the participant first aware of the disease? (dd/mm/yyyy)
(iii)
d. (i)
First date that the patient was warded / received treatment.
(ii)
If Yes, please state the clinic's / hospital's name and address.
e.
Jenis prosedur / rawatan yang telah diberi
Nature of procedure / treatment given
f. Tarikh prosedur / rawatan yang telah diberi
Nature of procedure / treatment given
Date
Tarikh pertama pesakit disahkan mendapat penyakit
tersebut
(dd/mm/yyyy)
Nyatakan dengan terperinci penyakit yang dihidapi
oleh peserta
Tarikh pertama peserta dimasukkan ke hospital /
menerima rawatan (dd/mm/yyyy)
Adakah peserta dirujuk dari klinik / hospital?
Jika Ya, sila nyatakan nama dan alamat klinik /
LAPORAN PERUBATAN TUNTUTAN KELUARGA
FAMILY CLAIMS MEDICAL REPORT
Nama Doktor dan Alamat
Tarikh pertama anda memberi rawatan. (dd/mm/yyyy)
Name and Address of Doctor
Tarikh Rawatan
Penyakit
Diagnosis
Was the patient referred from clinic / hospital?
Date you were first consulted.
Tarikh pertama simptom penyakit wujud? (dd/mm/yyyy)
First date symptoms of illness existed (dd/mm/yyyy).
FCL-PDM001_FRM016_00 Family Claims Medical Report (20092021)
g. (iv) * If 'YES', please state the illness and date of first diagnosed
Ya Tidak Nama penyakit / Kecederaan:
Yes No
Tarikh disahkan:
Date 1st disgnosed:
(v)
* If 'YES', please state the illness and date of first diagnosed
Hypertension Ya Tidak Date 1st diagnosed
Yes No
Diabetes Mellitus Ya Tidak Date 1st diagnosed
Yes No
Others Ya Tidak Name of illness:
Yes No
Date 1st diagnosed
h. Adakah keadaan ini berhubung kait dengan
Is the condition related to
(i) Mengandung Ya Tidak
Pregnancy Yes No
(ii)
Ketidaksiuman
Ya Tidak Date 1st diagnosed
Insanity Yes No
(iii) Kecacatan semasa lahir Ya Tidak Date 1st diagnosed
Congenital or Birth Defect
Yes No
(iv) Human Immunodeficiency Virus (HIV) / AIDS Ya Tidak Date 1st diagnosed
Human Immunodeficiency Virus (HIV) / AIDS Yes No
i.
Ya Tidak
Yes No
j. Nyatakan tempoh pesakit diwadkan.
Please state the duration when the patient was warded.
k. Nyatakan kesemua tempoh pesakit diwadkan
Please state all of the duration when the patient was warded
C.
PENGAKUAN / DECLARATION
Saya mengaku bahawa sepanjang pengetahuan keterangan di dalam laporan ini adalah benar dan betul dalam semua aspek.
I hereby declare that to the best of my knowledge and belief the foregoing particulars in this report are true and correct in every aspect.
Does the participant's condition related to attempted suicide or willful self
injury
Adakah keadaan yang dialami oleh peserta ini disebabkan lanjutan
daripada cubaan membunuh diri atau mencederakan diri sendiri
dengan sengaja?
Adakah apa-apa dalam sejarah pesakit yang mungkin
menyumbangkan secara langsung atau tidak langsung kepada
penyakit ini? (dd/mm/yyyy)
Is there in the patient's history that relates directly or indirectly to
this illness?
Adakah pesakit menghidapi penyakit-penyakit lain i.e. Diabetis,
Mellitus, darah tinggi atau masalah jantung? Jika Ya, sila
nyatakan sejak bila.
(dd/mm/yyyy)
Does the patient suffered any other illness such as i.e. Diabetes
mellitus, Hypertension or heart problem? If Yes, please state
Tandatangan Doktor / Signature of Doctor
Cop Rasmi Hospital / Hospital Official Stamp
Tarikh / Date
Tarikh Kemasukan ke Wad
Warded Duration
Penyakit
Diagnosis
FCL-PDM001_FRM016_00 Family Claims Medical Report (20092021)
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Completed 8 April 2022

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