英语翻译To fukoku Life Insurance CompanyEnglish only ; Please ty

英语翻译
To fukoku Life Insurance Company
English only ; Please type or write in block letters.
ATTENDING PHYSICIAN’S STATEMENT (PROOF OF HOSPITALIZATION)
1.Name of patient (Sex 口M口F) Date of birth
2.Name of sickness or injury for hospitalization
(口Presumption of doctor口Reported by patient )
Inception date of sickness or injury ___/___/20___
3.Treatment term
First medical consultation ___/___/20___
(Presently under treatment ___/___/20___)
1 st hospitalization ___/___/20___to___/___/20___
2 nd hospitalization ___/___/20___to___/___/20___
4.Condition of sickness from its start to the first diagnosis
(Plesse indicate when and how symptom first appeared)
Diagnosis and progress
5.Surgical operation effected
Type of operation
口Craniotomy 口Thoracotomy 口Laparotomy 口Operation using a fiberscope or a basket-lipvascular catheter on the brain.larynx,thoracic organs,and abdominal organs (excluding diagnostic procedures and temporary treatment) 口 Others
Name of operation
Date of operation ___/___/20___
6.Radiotherapy :Place____Period ___/___/20___to___/___/20___
Quantity in total_______Gy(Rads)_______
7.Previous illness (if any)
These statements are true and complete to the best of my knowledge and belief.
Name of hospital____Date___/___/20___
Address of hospital_______Country_______
Signature of doctor_______

致富国生命保险公司
请使用英语,并用清晰的大写字母打印或书写
主治医师报告（住院证明）
1.病人姓名（性别 口男 口女）出生日期
2.住院伤病名称
（口医生推测 口病人报告）
伤病起始日期___/___/20___
3.治疗措施
首次会诊___/___/20___
（目前仍在接受治疗___/___/20___）
第一次住院___/___/20___到___/___/20___
第二次住院___/___/20___到___/___/20___
4.首次诊断后疾病的状态
（请说明症状的开始时间和情况）
诊断和治疗进展
5.手术介入
手术种类
口开颅手术 口开胸手术 口开腹手术 口脑、喉、胸、腹的微创手术（不包括诊断性质或作为临时治疗的手术） 口其他
手术名称
手术时间___/___/20___
6.放疗：地点____ 期限___/___/20___到___/___/20___
辐射总量 ____Gy戈瑞(Rads拉德)
7.既往病史
本人特此申明这些报告都是真实而完整的.
医院名称 ____日期
医院地址____ 所在国家____
医师签名____