Medical Licensing Review Questionnaire
Please complete this questionnaire to assist in the review of your medical license application. Provide accurate and complete information for evaluation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Medical License Number (last 4 digits only)
*
Country or State of Medical License
*
Please Select
United States
Canada
United Kingdom
Australia
Other
Highest Medical Degree Earned
*
Please Select
MD
DO
MBBS
Other
Years of Medical Practice
*
Have you ever been subject to disciplinary action by a medical board?
*
No
Yes
Self-Assessment of Core Medical Competencies
*
Rows
Needs Improvement
Competent
Excellent
Medical Knowledge
1
2
3
Patient Care
4
5
6
Professionalism
7
8
9
Communication Skills
10
11
12
Ethical Practice
13
14
15
How confident are you in your current clinical skills?
*
1
2
3
4
5
What continuing education activities have you completed in the last 2 years?
Signature
*
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