Dear Physician/Practitioner,
(name) (gender) (DOB) Email (email) will be undertaking an internship/training program in the US from (start date) to (end date) for (#) of weeks. We kindly request your assistance in performing a concise examination, responding to the listed questions concerning the participant’s medical history, and providing any additional information that may be pertinent to their involvement in the program. Please ensure that all the above fields are filled out by pen or typing.
1 Allergies. Does the participant have any dietary restrictions or known allergies that the program should be aware of? If yes, please provide details (e.g., allergy types, severity, medication, previous history).
☐ Yes
☐ No
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2 Chronic or serious medical condition. Does the participant currently have, is the participant currently receiving treatment for, and/or has the participant been previously treated for any chronic or serious medical condition that the program should be aware of? If yes, please provide details (e.g., diseases/disorders, recommendation for ongoing/emergency treatment, medication).
☐ Yes
☐ No
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3 Disability. Does the participant require accommodations to a disability to enable them to participate in this program? If yes, please provide details.
☐ Yes
☐ No
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