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OFFICE USE ONLY Case Number: ___i MORGAN STATEUNIVERSITYA_MEDICAL INQUIRY FORM FOR EMPLOYEE ADA ACCOMMODATION REQUEST (To be completed by Health Care Provider) RETURN COMPLETED FORM TO: Khadija Fedora,
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How to fill out medical inquiry form
How to fill out medical inquiry form
01
Begin by reading all instructions on the medical inquiry form.
02
Provide accurate personal information such as name, address, date of birth, and contact details.
03
Fill out your medical history including any past illnesses, surgeries, and medications.
04
Be sure to include details of any allergies or sensitivities you may have.
05
If applicable, mention any current medical conditions or ongoing treatments.
06
Sign and date the form to certify that all information provided is accurate and complete.
Who needs medical inquiry form?
01
Individuals visiting a new healthcare provider for the first time.
02
Patients undergoing medical procedures or surgeries.
03
Individuals participating in clinical trials or research studies.
04
Individuals applying for specific insurance coverage.
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What is medical inquiry form?
Medical inquiry form is a document used to collect information about an individual's medical history and current health status.
Who is required to file medical inquiry form?
Healthcare professionals, insurance companies, employers, or government agencies may require individuals to fill out a medical inquiry form.
How to fill out medical inquiry form?
Individuals need to provide accurate and detailed information about their medical history, current health conditions, medications, allergies, and contact information.
What is the purpose of medical inquiry form?
The purpose of a medical inquiry form is to gather essential medical information to assess an individual's health status, make informed decisions, and provide appropriate care and treatment.
What information must be reported on medical inquiry form?
Information such as medical history, current health conditions, medications, allergies, surgeries, family history of diseases, and emergency contact information must be reported on the medical inquiry form.
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