MEDICAL EXAMINATION FORM

Swiss life insurance companies

Please note Select insurance...

We ask the physician to go through these questions together with the GLN
applicant and fill in the answers himself / herself if possible.
Please use block letters and write legibly. Thank you.
Insurers are prohibited by law from requesting the results of antenatal or
presymptomatic genetic tests (testing to see whether a person is
predisposed to illness before symptoms
appear) unless certain conditions are met. If the preconditions for the right to
ask questions are met, the investigation shall be carried out by using a
separate form. Therefore, such
findings do not have to be specified in the present questionnaire. Results
which are voluntarily submitted may not be used by the insurers.
Genetic examinations for diagnostic purposes, i. e. to clarify symptoms
of illness which have already occurred, are not affected by this legal
provision and must be declared.

Policy- / application no.

Applicant’s personal details

Surname Firstname Date of birth Description of the current occupation

Address Postcode City Country

Medical history
No. Questions No Yes If yes, please explain in detail (for all questions)
01 Do you exercise or practise sport regularly? Which?
How often?
02 Have you consumed or smoked tobaccos or nicotine in any Cigarettes E-Cigarettes Cigars Pipe
other form in the past 3 years?
Something else (e. g. water pipe, chewing tobacco, nicotine patch) What?
Daily amount? When was the last time?
03 Do you drink alcohol? Which drinks?
How much?
How often?
04 Are you or have you been, in the last 10 years, in consultation When?
or treatment in connection with your consumption of alcohol
By whom? Name and address
(incl. special clarifications / examinations / advising centre)?

05 Do you take drugs or have you taken any in the past 10 Which? How often?
years? How long? When was the last time?
06 Do you take medication regularly or repeatedly or have you Which? How often?
done so in the past 5 years or have been described
medications in the same period?
Why? From when to when?
07 a. Have you ever been hospitalised? Why?
When?
b. Did you undergo endoscopies of the joints or body cavities, Why?
catheter examinations or other surgical procedures?
When?
c. Do you currently present any illnesses / health conditions / Which?
consequences of accidents?

d. Is your ability to work or gain income limited in any way? Why?

Since when?
Degree / Extent?
e. Have you been completely or partially unable to work without Why?
interruption for more than 4 weeks during the last 5 years? From when to when?
f. Did you ever apply for any medical, educational, professional Which insurance?
or other measures at an insurance? When?
Why?
08 Have your parents, siblings or grandparents had any Wich
diseases of the nervous system, cardiac diseases, strokes, disease(s)?
diabetes, cancer or hereditary diseases before the age of 55?
How many persons?

Date and signature of the applicant Date Signature

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 No. Questions No Yes If yes, please explain in detail (for all questions)
09 Do you or did you have, in the last 10 years, any Which? When? Duration? Cured? Physicians / other therapists
diseases, disorders or problems connected with with addresses:

a. the respiratory organs, such as asthma, recurrent or

chronic bronchitis, pneumonia, pulmonary tuberculosis or
other problems?

b. the heart or vascular system, such as high blood pressure,

circulatory problems, heart attack, heart defect, heart failure,
cardiac dysrhythmia, stroke, phlebitis, varicose veins or other
problems?

c. the digestive system, such as hiatus hernia, gastric or

intestinal ulcer / inflammations / haemorrhages,
haemorrhoids, jaundice, diseases of the liver, gall bladder,
pancreas or other problems?

d. the urinary tract or sexual organs, such as diseases of the

kidneys, ureters, bladder, prostate or testicles, uterus or ovary
diseases, illnesses of the female breast, kidney / bladder
stones, blood or protein in the urine or other problems?

e. the nervous system, such as epilepsy, dizziness,

headache, paralysis, neuritis or other problems?

f. the mental state, i. e. mental disorders such as depression, anxiety,

stress, eating or psychosomatic disorders, burnout or other problems?

g. the musculoskeletal system (bones, joints, spine,

intervertebral discs, muscles, ligaments, tendons), such as
disorders of the back, neck or shoulders, arthrosis,
rheumatism or other problems?

h. the eyes, such as decreased visual acuity or refraction Diopters: left

power, cataract (lens opacity) or glaucoma, retinal disease or /right
other disorders?

i. the ear, such as hearing difficulties, inflammation, tinnitus

or other disorders?

j. the metabolism or blood, such as diabetes mellitus, elevated

cholesterol, gout, hormonal disturbances (thyroid gland, adrenal
glands), anaemia, coagulation disturbances or other disorders?

k. the immune system or infectious diseases, such as

HIV infection, sexually transmitted diseases, hepatitis, Lyme
disease, tropical diseases or other disorders?

l. due to skin disorders or allergies, e.g. to foods, pollen,

animal hair or others?

m. due to tumour diseases (benign or malignant)?

n. due to deformities or congenital defects?

o. due to consumption of or dependence on medications,

alcohol, drugs or other addictive substances?

p. other illnesses, disorders or problems not listed above?

10 Have you ever attempted suicide?

11 Are there medical consultations or treatments, a hospital stay or Why?

any surgery currently planned or recommended?

12 Have you consulted any physicians, chiropractors, Names and exact addresses
osteopaths, physiotherapists, psychotherapists or other
medical experts in the last 5 years that have not already
been mentioned? Why? When? Cured?

13 Which physician did you last consult? Names and exact addresses

Why? When? Results?

14 Which physician is most familiar with your medical history? Names and exact
addresses

I hereby declare that I have answered the above questions 1 to 14 honestly and completely. The validity of the contract depends
on the questions being answered correctly and completely. I authorise any doctors, medical institutions and insurance bodies
approached by the company to provide any information necessary for consideration of the application.
Place Date Signature of the applicant

I hereby confirm that I have handled each question above together with the applicant.
Place Date Signature of the physician

Medical examination form / medforms.40.50.40.5050.de / V110 2/5

 Medical evaluation of case history:

Medical examination including urinalysis

Please indicate and detail all pathological or abnormal findings. Thank you.

No. Questions No Yes If yes, please explain in detail (for all questions)
15 a. Date of medical examination:

b. Do you personally know the person to be insured? Personally known since:

Identity checked on the basis of:

Passport ID Driving licence Residence permit

c. Have you yourself previously examined or treated When?

the applicant?

Why?

Results?

16 Height (without shoes) / Weight (without clothes)

cm kg

17 Skin
Are there any signs of skin disease or scars?

18 Respiratory Organs
a. Are the results of percussion and auscultation abnormal? Cause?

b. Are there any signs of disease of the respiratory organs?

19 Heart and Circulation

a. Is there a heart murmur? If yes: systolic diastolic

Point of maximum intensity and transmission?

Is the heart murmur pathological?

b. Are there audible carotid murmurs?

c. Pulse rate, blood pressure Beats per minute

systolic diastolic
Blood pressure in mmHg

Blood pressure,
Please repeat measurement if the result is over 135 / 85 mmHg 2nd reading
d. Pulse rhythm regular irregular

e. Are there audible vascular sounds? Where?

f. Is pulsation of the pedal arteries absent or diminished?

g. Are there any signs of insufficiency or decompensation

(shortness of breath, cyanosis)?

h. Are there any varicose veins or signs of chronic venous

insufficiency?

Date and signature of the physician Date Signature

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 No. Questions No Yes If yes, please explain in detail (for all questions)
20 Digestive Organs and Abdomen
a. Are there any abnormalities of the teeth, tongue, tonsils,
mucous membrane or throat?
b. Are there any abnormalities on examination, palpation,
percussion and auscultation of the abdomen?

c. Is there a hernia?

21 Urinary Tract and Sexual Organs

a. For male applicants:
Is there any suspicion of disease of the urinary tract or
sexual organs?

b. For female applicants:

Is there any suspicion of disease of the urinary tract or
sexual organs, pathological breast abnormalities or is the
applicant pregnant?

22 Nervous System / Sense Organs

a. Are there any signs of disease of the sense organs,
particularly diminished sight or hearing?
b. Are there any indications of neurological diseases, disorders or
insufficiencies e. g. motor function, reflexes, sensitivity, balance?

23 Psyche
Are there any recognisable psychological or mental abnormalities
(e. g. inappropriate moodiness or abnormal behaviour) or are there
indications that there are currently stressful situations or conflicts?

24 Musculoskeletal System
Are there signs of spinal disease or deformations or any
other diseases of the musculoskeletal system?

25 Other
a. Are there any enlarged lymph nodes? Where?

b. Are there any indications of endocrinological disorders?

c. Is there any suspicion of eating disorders, alcohol abuse or

drug use?

d. Were there any other findings that could increase the risk
level?

26 Urinanalysis (urine test strip)

Urine contains protein?
Urine contains sugar?
Urine contains erythrocytes?
Urine contains leukocytes?
Urine contains something else?

IIf the results from the urine test strip show abnormalities,
please provide urinary sediment and quantitative data Ec Lc Other

hereby confirm that I have questioned and examined the applicant and have answered the above questions 15 to 26 to the best
of my knowledge and in good faith.
Place Date Signature of the physician

Medical examination form / medforms.40.50.40.5050.de / V110 4/5

 Comments:
(further conclusions, e. g. risk factors, suggestions for examinations and / or therapy)

Please enclose copies of available examination findings. Thank you

Physician's Phone Fax

address
GLN ZSR
eMail

Signature
when sent electronic obsolete

Date

Electronic
transmission
Der «Direkt-Versand» ist deaktiviert, weil der Empfänger nicht
gesichert erreicht werden kann (HIN-Mail|Medidata)!

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