• Medical History, Medications, and Specialist Information Form

  • Welcome!

    This questionnaire was created to establish well-rounded medical information about you. We believe that the more detailed information we have about you the patient, the better our IDL Medical Center team can manage your health with you. Please fill this form out to your best knowledge.

    P.S. We know it's quite long BUT very important, so thank you.

     

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  • SPECIALIST / MEDICAL TEAM LIST

  • PHARMACY

  • Medical History

  • SOCIAL HISTORY

  • MENTAL HEALTH

  • PERSONAL SAFETY

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  • Should be Empty: