DISABILITY CLAIM FORM Doctors part

DISABILITY CLAIM FORM (Doctors part)

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To be completed by the treating doctor

Patient’s name:

D.O.B.:

Address:

Occupation:

Diagnosis:

If is due to an Accident, when that happened?

If is due to illness, when that happened?

Where and when was the patient treated?

Since when do you treat the patient?

When was the last time you examined him/her?

Is the patient suffering or did he/she suffer from any illness, injury or any other disorder that might affect this incident? Give details:

What medical examinations took place in relation to this incident?