Get the free MEDICAL CLEARANCE AND REFERRAL FORM - dphhs mt

BMI kg/m2 a. Diagnosis of Yes No Declined b. History of Yes No c. Hypertension Dyslipidemia Pre-Diabetes Impaired Fasting Glucose IFG or Impaired Glucose Tolerance IGT N/A Gestational Diabetes Mellitus GDM N/A Gave Birth to a Baby 9 lbs Result from the CDC Pre-Diabetes Screening Test Prediabetes Risk Score d. High Blood Pressure Date measured // Systolic mmHg e. f. g. Diastolic mmHg HDL mg/dL Abnormal Glucose 2-hour OGTT mg/dL A1C Medications Triglycerides mg/dL or Fasting plasma glucose...

How to fill out medical clearance and referral

How to fill out medical clearance and referral

1. Step 1: Obtain the medical clearance and referral forms from your healthcare provider.
2. Step 2: Read the instructions on the forms carefully.
3. Step 3: Fill in your personal information accurately, including your full name, date of birth, and contact details.
4. Step 4: Provide your medical history, including any current medications or allergies.
5. Step 5: If required, attach any supporting documents such as previous test results or diagnostic reports.
6. Step 6: Review the completed forms to ensure all sections are filled out correctly and completely.
7. Step 7: Submit the forms to the appropriate authority or healthcare facility as per their instructions.
8. Step 8: Follow up with your healthcare provider to ensure the forms have been received and processed.
9. Step 9: Keep a copy of the completed forms for your records.

Who needs medical clearance and referral?

1. Individuals who are planning to undergo certain medical procedures, surgeries, or treatments may require medical clearance and referral.
2. Athletes participating in competitive sports or physical activities may need medical clearance to ensure their fitness level and identify any potential health risks.
3. Individuals with pre-existing medical conditions or a history of significant illnesses may need a medical clearance to assess their suitability for certain activities or treatments.
4. Patients being referred to a specialist or another healthcare provider by their primary care physician usually require a referral letter.
5. Employers or educational institutions may request medical clearance and referral for certain job positions or academic programs that involve physical or health-related requirements.

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What is medical clearance and referral?

Medical clearance is a process undertaken to determine if a patient is medically fit for a specific procedure or treatment. A referral is a recommendation from a healthcare provider to see another healthcare provider for further evaluation or treatment.

Who is required to file medical clearance and referral?

Patients who are scheduled for a medical procedure or treatment may be required to file medical clearance and referral, as requested by their healthcare provider.

How to fill out medical clearance and referral?

To fill out medical clearance and referral, patients need to provide their medical history, current medications, allergies, and any relevant test results to their healthcare provider.

What is the purpose of medical clearance and referral?

The purpose of medical clearance and referral is to ensure that the patient is in good health condition to undergo the planned procedure or treatment, and to coordinate care between healthcare providers.

What information must be reported on medical clearance and referral?

Medical history, current medications, allergies, recent test results, reason for referral, and any relevant information about the patient's health condition should be reported on medical clearance and referral.