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Office of the Lieutenant Governor (OLD) Department of Culture, Recreation and Tourism (DIRT) MEDICAL INQUIRY FORM RESPONSIVE TO ACCOMMODATION REQUEST FOR COMPLETION BY EMPLOYEE Employees Name:CONFIDENTIALITY

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How to fill out medical inquiry form

01

Start by providing your personal information such as name, date of birth, and contact details.

02

Fill out the medical history section by listing any previous medical conditions, surgeries, or medications.

03

Include details of any current symptoms or reasons for seeking medical assistance.

04

Make sure to accurately answer all questions honestly and thoroughly.

05

Review the form for completeness and accuracy before submitting it to the healthcare provider.

Who needs medical inquiry form?

01

Individuals who are seeking medical treatment or consultation from a healthcare provider.

02

Patients who are undergoing a medical examination, procedure, or surgery.

03

Individuals who need to provide their medical history to a new healthcare provider.

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What is medical inquiry form?

Medical inquiry form is a document used to collect medical information for a specific purpose.

Who is required to file medical inquiry form?

Individuals who are requested to provide medical information or whose medical information is necessary for a specific purpose are required to file medical inquiry form.

How to fill out medical inquiry form?

To fill out a medical inquiry form, you must provide accurate and detailed information about your medical history, current health status, and any relevant medical conditions.

What is the purpose of medical inquiry form?

The purpose of the medical inquiry form is to gather relevant medical information in order to make informed decisions or assessments.

What information must be reported on medical inquiry form?

The information that must be reported on a medical inquiry form typically includes personal details, medical history, current medical conditions, medications, and any relevant medical tests.

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