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Health Insurance
Medical Report

Directions
1. This form should be fully completed. Please print legibly in black ink.
2. This form will not be valid in case of erasures or overwriting, it will be submitted in original.
3. AXA Seguros will be released from any liability in case of misrepresentation or misstatement in the medical information
provided in this form.
4. This form is to be updated every 6 months or every time the treating physician is changed or the medical treatment or
medical condition changes.
5. Every treating physician or consulting physician will be required to complete a medical report.
Place: Date: Month Day Year

General Information
Data of the concerned Insured (patient)
Paternal surname: Maternal surname: First name(s):

Age: Date of birth: Month Day Year Sex: Height: Weight: Blood pressure:
Male Female
Reason for seeking medical care
Illness Accident Maternity Second medical opinion
Place of Service
Emergency Room Inpatient Short stay/outpatient Office visit
Past Medical History
Pathological history (please specify the onset date of illness or Non-pathological history (please specify frequency,
how long since you got ill mm/dd/yyyy): quantity and for how long)
Heart condition__________ High blood pressure Does the patient smoke?
___________________________ _____________________________________________
Diabetes mellitus________
Does the patient drink alcohol?
HIV/AIDS _________________
_____________________________________________
Cancer_______________
Liver condition______________ Does the patient do drugs?
Seizures______________ Other condition_____________ _____________________________________________
Obstetrics and Gynecology history Perinatal history (evolution, complications, treatments)
Gestation ____ Deliveries ____ Abortions ____ Cesarean Sections ____
Date of the last Month Day Year
menstruation:
Did you undergo
infertility treatment? _______________________
Time of evolution: ______________________________ Time of evolution: _______________________________
Referred by another physician or medical unit: Yes No Who/which? _____________________________________
AI - 346 • FEBRUARY 2019

Diagnosis
Current medical condition (main signs, symptoms and evolution details):

AXA Seguros, S.A. de C.V. Félix Cuevas 366, Piso 6, Col. Tlacoquemécatl, Del. Benito Juárez, 03200, CDMX, México • Tels. 5169 1000 • 01 800 900 1292 • axa.mx
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Medical Report

Date of medical condition: Month Day Year Date of diagnosis: Month Day Year

Congenital Acquired Acute Chronic Time of evolution _______________

Cause or etiology of medical condition (in case of accident, describe when, how and place of injury occurrence):

Is there any relationship with other medical condition? Yes No Which? _______________________________
Did the medical condition cause any disability? From: Month Day Year To: Month Day Year
Yes No Partial Total
Diagnosis, (stating whether unilateral or bilateral, right or left):

ICD Code: _________________________________ Is it cancer: Yes No TNM stage:_______________

Physical Examination:

Laboratory and Radiological Data:

Plan or treatment
Proposed treatment (surgical, non-surgical): Date of Surgery:
Month Day Year

Inpatient date: Month Day Year Discharge date: Month Day Year

Days during which medical care was provided:

Where will the procedure will be performed?
Doctor’s office Hospital Imaging center Other Specify: ______________________________
Provider Name:
AI - 346 • FEBRUARY 2019

Was a histopathologic study conducted? Yes No

Describe the results of the study:

AXA Seguros, S.A. de C.V. Félix Cuevas 366, Piso 6, Col. Tlacoquemécatl, Del. Benito Juárez, 03200, CDMX, México • Tels. 5169 1000 • 01 800 900 1292 • axa.mx
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Health Insurance
Medical Report

Did complications arise? Yes No

Describe the complications:

Will the Insured continue to get treatment in the future? Yes No

Plan or treatment:

Other treatments and/or materials, equipment and/or biological/monitoring

Specify treatment (Chemotherapy cycles, physical therapy sessions, number of rounds/sessions, quantity, frequency and how long):

Scheduling of rounds of chemotherapy or radiation therapy sessions (should more than 10 drugs are prescribed,
please fill out another form)
# Name and presentation of the drug Quantity Frequency How long
(e.g. acetaminophen 100 mg) (e.g. 1 tablet) (e.g. every 24 hours) (e.g. For one month)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Scheduling of physical therapy sessions

Days: _______________________ Number of sessions: __________________________
Home care
AI - 346 • FEBRUARY 2019

Days required: ________ Morning Evening Night 24 hours

Name of medicines:

AXA Seguros, S.A. de C.V. Félix Cuevas 366, Piso 6, Col. Tlacoquemécatl, Del. Benito Juárez, 03200, CDMX, México • Tels. 5169 1000 • 01 800 900 1292 • axa.mx
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Health Insurance
Medical Report

In case of immunotherapy, biological therapy, etc., justify the treatment:

List of materials used or that will be used during surgery and/or special equipment (monitor, Da Vinci or others):

Type of therapy: Certificate of specialization:

Evolution detail:

Comments
If there is any additional comment, please include them here:

Physician information
Physician or specialist
Type of participation

Name
AI - 346 • FEBRUARY 2019

Specialty

Board member ID

Address

Phone number

AXA Seguros, S.A. de C.V. Félix Cuevas 366, Piso 6, Col. Tlacoquemécatl, Del. Benito Juárez, 03200, CDMX, México • Tels. 5169 1000 • 01 800 900 1292 • axa.mx
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Health Insurance
Medical Report

Signature of the Physician Place and date

In case of reimbursement and/or service scheduling, the Insured must fill out the following section:
Personal Data
AXA Seguros S.A. de C.V. (AXA), with address at Avenida Félix Cuevas número 366, piso 6, Colonia Tlacoquemécatl,
Delegación Benito Juárez, C.P. 03200, Mexico City, will process your personal data to comply with the Insurance Contract
and all other purposes stated in the full privacy notice at axa.mx under the Privacy Notice section.
I authorize my personal data, both my financial and assets information, to be processed and transferred for the purpose
of complying with the Insurance Contract and all other purposes stated in the Privacy Notice.
Transfer of Data to third parties
To be filled in by the concerned Insured, or in the absence thereof by the parents or guardians in case the Insured is a minor.
I authorize AXA to process my sensitive personal data and to transfer them to physicians in Mexico and/or abroad as well as
to medical service providers with whom it has entered into an agreement for the purpose of complying with the obligations
deriving from the Insurance Contract.

Yes, I do Signature of the Insured:_______________________________

No, I do not
I authorize AXA Seguros S.A. de C.V., upon my registration to any of the programs included in the major medical expenses
insurance policy, to transfer my sensitive personal data to specialized physicians in Mexico and/or abroad as well as to service
providers, so they offer me assistance services for a specific follow-up of my medical condition and so I can request a second
medical opinion and, if applicable, so they offer me alternatives for the treatment of my illness

Yes, I do Signature of the Insured:_______________________________

No, I do not
This translation is only a courtesy, for any situation related to its content the version in its original language (Spanish) will prevail
for all contractual and legal effects.

AI - 346 • FEBRUARY 2019

AXA Seguros, S.A. de C.V. Félix Cuevas 366, Piso 6, Col. Tlacoquemécatl, Del. Benito Juárez, 03200, CDMX, México • Tels. 5169 1000 • 01 800 900 1292 • axa.mx