To MetLife

To MetLife
PROOF OF HOSPITALIZATION (Attending Physician’s Statement)
English only: Please type or write in block letters .
1．Patient’s information
Patient’s name
Gender
(患者氏名)
□ Male
□ Female
Day
Date of
birth
Month
/
Year
/
2．Name of sickness / injury
a) Name of sickness / injury
requiring hospitalization
Day
Inception date of a)
/
(aの発生日)
(入院の原因となった傷病名)
b) Cause of a)
(aの原因)
Day
Inception date of b)
Day
Inception date of c)
/
Year
/
Month
/
(cの発生日)
Year
Month
/
(bの発生日)
c) Complication
(合併症)
Month
Year
/
3. Treatment term
Day
Treatment period
/
(治療期間)
Day
1st hospitalization
hospitalization
4. After effect
Month
Day
Day
to
Month
Day
to
Month
Day
to
Year
□ Finished treatment(終診)
□ Currently under treatment(治療中)
/
/
Year
/
Month
/
Year
/
/
(第2回入院)
Year
/
/
(第1回入院)
2nd
Month
Year
/
Month
/
Year
/
□ Discharged (退院)
□ Currently hospitalized
(入院中)
□ Discharged (退院)
□ Currently hospitalized
(入院中)
❖ Please check the appropriate box.
Did the patient need restriction to work for 60 consecutive days or more after the inception?
□ Yes / □ No
(発症から60日以上、労働制限を要する状態が継続しましたか?)
Did the patient experience after effect of central nervous systems for 60 consecutive days or more after the first inception?
□ Yes / □ No
(発症から60日以上、他覚的な神経学的後遺症が継続しましたか?)
5. In case of cancer
Final diagnosis on
histopathological exam
TNM
Staging T(
(最終病理組織検査結果)
) N( ) M( )
Date of
diagnosis
Day
Month
/
Year
/
6. Description of conditions and progress of sickness / injury since the initial consultation
Please indicate when and how symptom first appeared.
Conditions of sickness /
injury since the first
consultation
(発症から初診までの経過)
7. Diagnosis and progress
Please provide detail of diagnosis and progress.
Diagnosis and progress
(診断結果および経過)
8. Surgical Operation
Date of
operation
Name
(手術名)
1st Operation
(第１回手術)
Type
(種類)
□Craniotomy (開頭術)
□Laser (ﾚｰｻﾞｰ)
□Other〔
□Trepanation (穿頭術)
□Endoscope or catheter
□Thoracotomy (開胸術)
(内視鏡・ｶﾃｰﾃﾙ)
Type
(種類)
/
Year
/
〕
(手術名)
(第2回手術)
Month
□Celiotomy (開腹術)
□Hyperthermia for cancer(温熱療法)
Date of
operation
Name
2nd Operation
Day
□Craniotomy (開頭術)
□Laser (ﾚｰｻﾞｰ)
□Other〔
□Trepanation (穿頭術)
□Endoscope or catheter
□Thoracotomy (開胸術)
(内視鏡・ｶﾃｰﾃﾙ)
Day
Month
/
Year
/
□Celiotomy (開腹術)
□Hyperthermia for cancer(温熱療法)
〕
9. Radiotherapy
Radiotherapy period
(放射線照射期間)
Day
Month
/
Year
/
Day
to
Month
/
Year
Total quantity
/
Gray
(総線量)
10. Previous illness
Medical history (If any)
Please provide name of illness, treatment term and any other pertinent information.
(前医・既往症)
These statements are true and complete to the best of my knowledge and belief.
Name of hospital:
Address of hospital:
Country of hospital:
Phone number:
Signature of Physician:
メットライフ生命
入院・手術等証明書（診断書）海外用
※受療した病院の医師へ、本紙の証明をご依頼ください。
Day
Date
Month
/
Year
/
Print name:
CK-CL-14-0497 D保金001(4)(14.07) 000741_3

Download Report