Medical Evaluation Template


A medical evaluation template serves as a basic design to write a medical evaluation report. It is created carefully as it must include all the details pertaining to the medical evaluation report. It is authorised by experts and professionals in the field of medical science to examine the dangers and risks allied with a substance and its use.

Sample Medical Evaluation Template

Nature of the substance evaluated: _____________________________ [Mention the type of material being evaluated whether it is a natural or a chemical product]

Medical evaluation commissioned by: ______________________________ [Mention the organization or company commissioning such the medical evaluation]

Date of submission of medical evaluation report: _________________________ [Mention the appropriate date]

Medical evaluation conducted by: ____________________________________ [Provide the name of the organization or department conducting the medical evaluation. Mention the names of the chief members]

Purpose of medical evaluation:

  • Purpose 1: _________________________________
  • Purpose 2: _________________________________
  • Purpose 3: _________________________________ [Enlist the benefits that will be accrued through this medical evaluation]

Techniques used for medical evaluation:

  • Technique 1: ___________________________
  • Technique 2: ___________________________
  • Technique 3: ____________________________ [Mention the testing methods of evaluation adopted in the medical evaluation]

Factors considered in medical evaluation:

  • Nature of the substance: _________________________________________
  • Method of application: __________________________________________
  • Nature of use: _________________________________________________
  • Degree of solvency and contamination: _____________________________
  • Wastes generated by its use: ______________________________________
  • Components and their percentage: ___________________________________ [State how the factors have played a part in the evaluation process]

Medical evaluation report compiled by: _____________________________ [Provide the relevant details]

For more information please contact: _______________________________ [Provide the contact numbers]

Download Medical Evaluation Template

Category: Medical Evaluation

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