Medical Questionnaire Demo

Please answer questions as completely as possible. Be honest because CRC will be able to look up your records from past military, VA, and TriCare records. If there are any issues that come up, we are here to help you by submitting any eligible waivers necessary before you arrive at CRC. Estimate if you are unsure. This information will be used for patient registration as well as populating government forms which ask for ss#, dob, and other personal information.

If your participating in this prescreening on behalf of your employer, submitting the following health information gives consent for Access One Medical to share pertinent health information to your employer about your ability to clear CRC medical, CENTCOM Mod 13, and other Army medical requirements for the purpose of deployment.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

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Please complete all sections

First Name*

Middle Name or Initial

Last Name*

Social Security Number - Necessary for DD2807*

Date of Birth*

Address*

City, State, Zip Code*

Phone Number*

Email Address*

What company do you work for?*

Please list all countries you will be going to.*

What is your estimated deploy date?*

How long will you be deployed?*

Thank you for using Access One's Clear2Deploy service.

You records will be reviewed within 2 business days.

Please watch for an email from Access One that will explain how to get your lab work completed anywhere in the United States and some other select countries.

If you have any questions please call us at 915-777-3987 or you can email us at info@Access1med.com.