Medical Clearance Form Template

This Medical Clearance Form Template is carefully build to help medical professionals and healthcare providers in evaluating the fitness level of patients before any surgery or discharging from hospital. It collects patient details along with their diagnosis, severity, and medications to assess their health before moving to the next step.

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Understanding Medical Clearance Form Template

Every healthcare institution or provider needs to evaluate the patient's diagnosis, severity, and current medications before they move forward with any treatment, surgery, physical fitness test, or even for releasing them from the hospital. The details can help personalize the care, take required precautions, and be better prepared.

The Medical Clearance Form Template is meant to be filled by the patient, the relative, or the guardian. It collects the patient's details like name, number, date of birth, blood group, etc. In addition to that, it also collects information regarding the nature of clearance, diagnosis, medication, and more.

You can sign in or sign up with Zonka Feedback and use the Medical Clearance Form Template to create and run your surveys for free. Collect the useful information from patients and ensure the right treatment.

9 Questions

7Screens

1 min to complete

List of Medical Clearance Form Questions

The following questions are included in this Medical Clearance Form Template.

Can you please tell us the patient's name?
Can you tell us the patient's date of birth?
Can you please help us with filling other details of the patient- Email, Mobile Number, Address, Blood Group
Can you tell the nature of the clearance?
Tell us about the patient's diagnosis and severity?
What are the current medications of the patient?

Sign Up or Sign In on Zonka Feedback for free and try this Medical Clearance Form Template to collect patient data about their health and fitness to get a green light and move further with surgery or release.

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