(To be completed by medical attendant)
Please note that it is essential to complete this form in full to prevent unnecessary delays as a result of missing information. Please note that should there be any charges for the completion of this form, such charges will be for the life insured’s account. The following must be included when submitting this form: To assess the claimant’s degree of impairment (medical assessment), and to ascertain: Diagnosis Alteration(s) of functional capacity due to illness or injury Optimal medical treatment Return the completed form and the above documents to lifeclaims@hollard.co.za or fax to 086 659 0135.
Life assured details
Policy no.	ID no.
Name of insured
Policy owner
Employer	Occupation
Date of first consultation	D D M M Y Y Y Y
Date of last consultation	D D M M Y Y Y Y
Date of diagnosis of the claimant’s illness	D D M M Y Y Y Y
What was the diagnosis of the claimant’s condition?
What were the symptoms?
When did the first symptoms of the condition appear?	D D M M Y Y Y Y
What has caused the disability?
What are the resultant limitations experienced?
Provide details of any complications or concurrent conditions
Are you still attending to the claimant?	Yes	No
Does the claimant have insight into his/her illness?	Yes	No
Provide details of all consultations in the last 5 years
Date	Reason for consultation	Diagnosis	Treatment	Outcome
Has the claimant ever been hospitalised?	Yes	No
Provide details of hospitalisation
Date from	To	Reason for hospitalisation	Hospital/Doctor	Treatment	Outcome
Has the claimant been referred to any health care professionals, e.g. physiotherapists, occupational therapists, psychologists, or other medical specialists?	Yes	No
Provide details
Name	Designation	From	To	Treatment	Outcome
Have any of the following contributed in any way to the claimant’s disablement?
Nature of contributor, and give details
Previous illness or injury	Yes	No
Hazardous pursuit or pastime	Yes	No
Habits (e.g. excessive alcohol consumption, smoking)	Yes	No
Self-inflicted injuries	Yes	No
How has the patient’s condition been treated?
Date	Therapy/Medication	Description/Dosage
Describe fully, in detail
Strict compliance by claimant with medication/therapy	Yes	No
Is the condition satisfactorily controlled?	Yes	No
Is the claimant undergoing optimal therapy?	Yes	No
Is future surgery planned/required/anticipated?	Yes	No
If so, when?	D D M M Y Y Y Y

Any additional comments
Give an indication of the short-term and long-term prognosis with reasons
Assessment scale for activities of daily living
Washing	The ability to wash in the bath or shower (including getting into and out of the bath or shower) or wash by other means	Can	With help	Cannot
Mobility	The ability to move indoors from room to room on level surfaces and outdoors for 200 m on level surfaces	Can	With help	Cannot
Transferring	The ability to move from a bed to an upright chair or wheelchair and vice versa	Can	With help	Cannot
Dressing	The ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or other surgical appliances	Can	With help	Cannot
Feeding	The ability to cut food as well as to get food and/or drink to the mouth	Can	With help	Cannot
Toileting	The ability to use the lavatory or manage bowel and bladder functions through the use of protective undergarments or surgical appliances, if appropriate. This includes the maintenance of continence	Can	With help	Cannot
Communicating	The ability to answer the telephone and take a message	Can	With help	Cannot
Reading	Having the eyesight required to be able to read a newspaper, book or magazine	Can	With help	Cannot
Bending and lifting	The ability to get into and out of a standard size car, bend, kneel or pick up something from the floor, lift, carry or move everyday objects	Can	With help	Cannot
Co-ordination	The ability to use hands and fingers with precision, including the ability to pick up and manipulate small objects, such as pens or cutlery	Can	With help	Cannot
D D M M Y Y Y Y In your opinion, at which date was the claimant last able to work?
D D M M Y Y Y Y When is the claimant expected to return to work?
In your opinion, when will the claimant be able to engage in any part of his/her occupation?
Part-time: Admin Sedentary Travel Manual Supervisory	D D M M Y Y Y Y
Full-time: Admin Sedentary Travel Manual Supervisory	D D M M Y Y Y Y
If the life assured has already recovered and returned to work, please give the date of his/her return	D D M M Y Y Y Y
IF ADDITIONAL INFORMATION OR REPORTS ARE AVAILBLE, PLEASE INCLUDE COPIES OR ORIGINALS OF THESE DOCUMENTS. ANY ORIGINALS WILL BE RETURNED.
ALL THE INFORMATION GIVEN IS CORRECT AND TRUE.

Notice to medical attendants
Practice no.	Qualifications
Tel. no.	Fax no.
Full name
E-mail address	Mandatory
Postal address
Declaration by medical attendant
I declare that I have personally attended to the patient and that the statements above are true and complete.
Signature	Date	D D M M Y Y Y Y