Diagnostic Impression. 16. Is there any abnormality of the following: (CIRCLE APPLICABLE ITEMS AND GIVE DETAILS) Yes No (a) Eyes, ears, nose, mouth, pharynx.............. [_] [_] (IF VISION OR HEARING MARKEDLY IMPAIRED, INDICATE DEGREE AND CORRECTION) (b) Skin (incl. scars); lymph nodes; blood vessels...................................... [_] [_] (INCL. VARICOSE VEINS) (c) Nervous system (INCLUDE REFLEXES, GAIT, PARALYSIS)................................... [_] [_] (d) Respiratory system........................... [_] [_] (e) Abdomen (INCLUDING SCARS OR HERNIAS)......... [_] [_] (f) Genitourinary system......................... [_] [_] (g) Endocrine system (INCLUDE THYROID AND BREASTS)..................................... [_] [_] (h) Musculoskeletal system....................... [_] [_] (INCLUDE SPINE, JOINTS, AMPUTATIONS, DEFORMITIES) ------------------------------------------------------------------- 17. Have you any pertinent information not brought out above?........................................ [_] [_] ------------------------------------------------------------------------------------------------------------------------------------ MEDICAL EXAMINER: EXAMINER'S NAME AND OFFICE ADDRESS (PLEASE PRINT) X_________________________________________________ Name___________________________________________________________ SIGNATURE OF MEDICAL EXAMINER Street_________________________________________________________ WHEN PAYING FEES WE ARE REQUIRED TO SHOW AND REPORT SOCIAL SECURITY OR EMPLOYER I.D. NUMBER. PLEASE City___________________________________________________________ GIVE US THIS INFORMATION BELOW. Include All Hyphens [_____________________________] State__________________________________________________________
Appears in 5 contracts
Samples: Pacific Select Exec Separate Acct Pacific Life Ins, Pacific Select Exec Separate Acct Pacific Life Ins, Pacific Select Exec Separate Acct Pacific Life Ins
