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of 12The Travel Doctor-TMVC Medform 1 Standard Pre-Assignment Medical AssessmentVersion 3 Revised 03/2016 1
Client name
Date of birth
Standard Pre-Assignment Medical Assessment
Medform 1
PERSONAL DETAILS To be completed by examinee
Examinee identification Employee Family Member Other
Pre placement medical examination Other
Surname Date of birth (dd/mm/yy) Given Names Male Female Marital status (for visa purpose) Married Single
Home address Suburb Postcode Telephone home Telephone work Mobile Fax Email (for medical communications and follow-up)
Overseas Assignment/Reassignment Company/sponsoring organisation Position City Country If family member, what is full name of employee Length of stay Proposed date of departure from Australia (dd/mm/yy)
Name & address of general practitioner or treating specialist (if nominated)
Name Telephone work Address Suburb Postcode
PERSONAL STATEMENT To be completed in the presence of the examining Doctor
I declare the information provided by me to be full & correct to the best of my knowledge. I understand the record will be retained in a safe & secure confidential manner.
I understand that a copy of the full medical/summary page only (Travel Doctor to delete one) will be given to the employing company.
I hereby authorise my regular attendant or any other doctor to release details of my personal history to the Medical Director, The Travel Doctor-TMVC
In the event of a medical emergency, I give permission for my records to be made available by the Medical Director, The Travel Doctor-TMVC
Signature (Examinee) Date (dd/mm/yy) Signature (Medical Examiner) Date (dd/mm/yy)
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
PART 1 – QUESTIONNAIRE To be completed by examinee
Instructions: To help protect your health overseas, it is important for the examining doctor to find out about your past & present health status. The questions below are designed to pick up specific health problems or concerns & to provide a basis upon which specific advice might be provided. It is important that you answer all questions by ticking the appropriate box. If you have any queries, please direct them to the examining doctor for clarification. The information will form part of a CONFIDENTIAL permanent health record retained by THE TRAVEL DOCTOR (TMVC).
A. PERSONAL HISTORY
Do you have now, have ever had or have you been treated for any of the following conditions? Please tick Yes (Y) or No (N) in the appropriate box
1. GASTROINTESTINAL
1.1 Dyspepsia, indigestion, acid reflux, gastric, peptic or duodenal ulcer or hiatus hernia? Y N
1.2 Frequent nausea or vomiting or vomiting of blood? Y N
1.3 Passing of blood from the anus or rectum, black motions, haemorrhoids, fistula, anal fissure or pilonidal sinus? Y N
1.4 Liver disease, hepatitis, gallstones or gall bladder disease, biliary colic or pancreatitis? Y N
1.5 Abdominal pain or colic, irritable bowel disease, recurring diarrhoea or constipation, ulcerative colitis or Crohn’s disease? Y N
1.6 Unexplained weight loss? Y N
1.7 Hernia, or any abdominal operation? Y N
2. CARDIOVASCULAR
2.1 Heart disease, any investigation of the heart including ECG, stress ECG, echo or ultrasound or heart operation of any nature? Y N
2.2 Any problem with blood pressure including high blood pressure (hypertension), low blood pressure, postural hypotension, dizziness, loss of balance or fainting? Y N
2.3 High blood cholesterol or triglycerides? Y N
2.4 Chest pain or discomfort on exertion, shortness of breath on exertion? Y N
2.5 Palpitations or consciousness of your heart beat, arrhythmia or irregularities of pulse or heart rate? Y N
2.6 Heart murmur or rheumatic fever? Y N
2.7 Swelling of feet, ankles, varicose veins, peripheral vascular disease? Y N
2.8 Any other condition of blood vessels (eg arteritis)? Y N
3. RESPIRATORY
3.1 Chronic or persistent cough, coughing up blood or phlegm? Y N
3.2 Bronchitis, pneumonia, pleurisy, fluid on the lung, emphysema or chronic obstructive airways disease? Y N
3.3 Pneumothorax (collapsed lung)? Y N
3.4 Tuberculosis or positive Mantoux test for whatever reason? Y N
3.5 Asthma, wheezing, use of inhaler or “puffer”? Y N
3.6 Any other lung disease or chest complaint or problem with breathing? Y N
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
4. MUSCULOSKELETAL
4.1Neck pain/ injury, back pain/ injury or history of strain “whiplash” injury or history or vertebral disc disorder? Y N
4.2 Stiff or painful joints, arthritis, gout, polyarthritis, osteoarthritis or rheumatoid arthritis? Y N
4.3 Polio, paralysis or muscle weakness, limitation of movement or irregularity of gait? Y N
4.4 Repetitive strain injury (RSI) or occupational overuse syndrome? Y N
4.5 Any other upper or lower limb disorder, spinal or orthopaedic condition or surgery, or any other condition of the muscles, bones, or joints (including broken bones)?
Y N
5. EYE, EAR, NOSE & THROAT
5.1 Any eye disorder or operation, including need for glasses or contact lenses, radial keratotomy, or laser surgery? Y N
5.2 Colour perception problems? Y N
5.3 Persistent ear or sinus problems, ear infections, or perforated ear drum or operation? Y N
5.4 Deafness or poor hearing? Y N
5.5 Tinnitus (ringing in the ears), dizziness or loss of balance? Y N
5.6 Nasal obstruction, allergy, hayfever or allergic rhinitis? Y N
6. BLOOD, ENDOCRINE & IMMUNITY
6.1 Tiredness, lethargy, investigations for anaemia or leukaemia? Y N
6.2 Any blood disorder, bleeding problem, clotting disorder, DVT or pulmonary embolism (clot travelling to the lung)? Y N
6.3 Thyroid disorder or surgery? Y N
6.4 Diabetes or abnormal glucose metabolism? Y N
6.5 Significant alteration in weight over the last 12 months? Y N
7. GENITO-URINARY SYSTEM
7.1 Difficulty or pain passing urine, blood in the urine or abnormal urinary tests? Y N
7.2 Any kidney or bladder disease or infection (eg cystitis, nephritis, kidney stones), investigation or operation? Y N
8. SKIN
8.1 Any chronic, persistent or intermittent skin condition such as urticaria (hives) eczema, dermatitis, or psoriasis? Y N
8.2 Any skin reactions to occupational contact chemicals or allergic reactions to any specific agent? Y N
9. NEUROLOGICAL
9.1 Have you ever had to take medication to relieve symptoms of anxiety, depression, situational stress or any nervous disorder? Y N
9.2 Any history of psychiatric, behavioural or psychological condition or need for counselling? Y N
9.3 Claustrophobia or fear of flying? Y N
9.4 Post traumatic stress disorder? Y N
9.5 Epilepsy or any type of fit or funny turn? Y N
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
9.6 Frequent or severe headaches, migraine or cluster headaches? Y N
9.7 Unconsciousness or loss of memory? Y N
9.8 Insomnia or other sleep disorder? Y N
9.9 Persistent disturbance of sensation such as tingling, numbness or pain, or carpal tunnel syndrome? Y N
9.10 Head injury or concussion? Y N
9.11 Any other neurological disorder? Y N
10. OTHER
10.1 Any dental problems, dentures or history of restorative dental work? Y N
10.2 Any problems with the last molar teeth (wisdom teeth)? Y N
10.3 Years since last dental check?
10.4 Any form of cancer or tumour, including skin cancer? Y N
10.5 Any other health matter which may be relevant, or that may affect working under stressful situations particularly in a cross cultural setting? Y N
10.6 Any hospitalisation or other medical condition, operations or investigations not already mentioned? Y N
10.7 Any proposal to insure you for life, sickness or disability insurance or superannuation, accepted on special terms, deferred or declined? Y N
10.8 Do you have any active infective disease? Y N
10.9 Have you ever had any travel-related illness eg malaria, dengue fever, typhoid, schistosomiasis (bilharzia) or gastrointestinal disease eg giardia Y N
11. WOMEN ONLY
11.1 Are you pregnant now? Y N
11.2 If you have been previously pregnant, were there any problems? Y N
11.3 Do you have any menstrual problems? Y N
11.4 Are you prone to vaginal thrush? Y N
11.5 What was the date of your last pap smear?
11.6 Have you ever had an abnormal pap smear? Y N
11.7 Have you ever had a screening mammogram? Y N
11.8 If you have had a mammogram, when was it last done?
11.9 Have you ever been investigated for a breast problem? Y N
11.10 Have you gone through the menopause? Y N
11.11 Have you had any other gynaecological or urinary problems or operations? Y N
12. MEN ONLY
12.1 Have you ever had or have any testicular problems (eg hydrocoele, varicocoele, undescended testicles), any operation on the scrotum including vasectomy? Y N
12.2 Have you had any genitourinary problem or operation? Y N
12.3 Have you had any problem relating to the prostate? Y N
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
B. FAMILY HISTORY
Tick any of the following conditions that a close member of your family may have suffered. Consider only your parents & siblings.
High blood pressure Stroke Other heart condition Blood or clotting disorder
Diabetes High cholesterol Breast Cancer Bowel cancer
Hip fracture Family inherited disorder Early coronary artery disease < 55 in male < 65 in female
Doctor’s comments
C. MEDICATIONS
Tick if you take medications for any of the following conditions
High blood pressure Diabetes High cholesterol Epilepsy
Heart condition Depression Blood thinning Gastric reflux
Other, specify
Name of medication/s if taking (including over-the-counter)
Doctor’s comments
D. ALLERGIES
Do you have any allergies to medications (eg penicillin, sulfa)? Yes No
If yes, please list
E. SMOKING
1.1 Do you currently smoke? Yes No If Yes, how many do you smoke daily? 1.2 Did you smoke in the past? Yes No If so, how many years and when did you stop?
F. ALCOHOL HISTORY
How often do you consume alcohol?
Never or very occasional Once per week On 1-2 days of the week
On 3-4 days per week On 5-6 days per week Every day
On a day when you consume alcohol, how many standard drinks do you usually have?(A standard drink contains about 10g alcohol – 1 glass (285mL) of normal beer, 1 glass of table wine (100ml), 1 glass of fortified wine (60mL),
or 1 nip of spirits (30mL). Two cans of normal beer would equal 3 standard drinks)
1-2 drinks 3-4 drinks 5-8 drinks More than 8 drinks
How often would you have more than 6 standard drinks on one occasion?
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
G. LIFESTYLE
On average how many times per week would you undertake exercise lasting more than 20 minutes?
What type or exercise or sport do you currently undertake or plan to undertake in the future?
H. TRAVEL MEDICINES & VACCINATIONS
Have you ever taken medications for malaria prevention before? Yes No
If so, which ones & for how long? Did you experience any special issues with them?
Please tell us about your previous vaccinations. You may need to refer to your vaccine records. You can write the name of the vaccination if you wish.
Vaccine Last dose received (approx.) CommentsInfluenza
Polio
Tetanus
Measles
Chicken Pox
Hepatitis A Full Course complete? Yes No
Hepatitis B Full Course complete? Yes No
Typhoid
Meningitis
Yellow Fever
Rabies Full Course complete? Yes No
Japanese Encephalitis Full Course complete? Yes No
Cholera (Oral)
Thank you. The rest of the form is for the examining Doctor to complete. Please remember to bring your previous vaccination records or any relevant medical reports for the examination.
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
THIS SECTION FOR DOCTORS USE - Questions in Section A which elicit a postive answer must be commented upon
Please indicate duration, severity, functional implications or impairment from any medical condition. Please note the question number against any comment.
Any other concerns or comments?
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
PART 2 – MEDICAL To be completed by examining Doctor
The purpose of this health assessment is two-fold. Firstly to ensure the person is fit for the proposed overseas placement, and secondly to ensure that all appropriate health measures (vaccinations, medications, screening) have been undertaken prior to travel. To achieve this you are requested to review the questionnaire with particular attention to the positive responses. Provide advice as required. Ensure immunisations are in train or completed & medications & malaria prophylaxis completed where necessary.(check if relevant work-instruction applies). Consider the need for specialist or treating practitioner reports.
1. Height (cm) 2. Weight (kg) 3. BMI
4. Blood pressure (Repeat after 5 minutes if >130/85)
Before rest After restSystolic
Diastolic
5. Pulse
6. Abdominal Girth
7. Urinalysis (please record) Blood Sugar Protein
8. Visual Acuity Without correction R 6 L 6 With correction R 6 L 6
9. Colour Perception (Ishihara) Normal Abnormal
10. Clinical Evaluation (tick appropriate column)
Abnormal Not Exam Normal Abnormal Not Exam Normal
10.1 Eyes (external) 10.13 Abdomen
10.2 Eyes (Fundi) 10.14 Hernial Orifices
10.3 Hearing (spoken voice) 10.15 Breasts
10.5 Nose & sinuses (if indicated)
10.17 Anus & rectum (if indicated by Hx)
10.6 Mouth, teeth, throat10.18 Prostate exam (If indicated by Hx)
10.7 Neck & thyroid 10.19 Reflexes
10.8 Heart 10.20 Peripheral pulses
10.9 Chest & Lungs 10.21 Peripheral veins
10.10 Skin 10.22 Lymph nodes
10.11 Spine 10.23 Range of Movt
10.12 Psychological 10.24 Muscle Tone & Power
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
EXAMINATION COMMENTS AS REQUIRED
INVESTIGATIONS (as indicated from history & examination & with agreement from the company – see next page)
Name of Medical Examiner (BLOCK CAPITALS) Qualifications Address Postcode Telephone Fax
Signature (Medical Examiner) Date (dd/mm/yy)
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
MEDICAL INVESTIGATIONS AS INDICATED (Please refer to work instructions)
Test Requested Completed Result
Blood Group Yes No Yes No
Full Blood Count Yes No Yes No
LFTs Yes No Yes No
Fasting Cholesterol / Triglycerides Yes No Yes No
Blood Sugar Yes No Yes No
Urine Drug / Alcohol Yes No Yes No
Quantiferon-Gold Test Yes No Yes No
HIV Screen Yes No Yes No
Hep A Serology Yes No Yes No
Hep B Serology Yes No Yes No
Hep C Serology Yes No Yes No
ECG Yes No Yes No
Cardiac Stress Test Yes No Yes No
CXR Yes No Yes No
Spirometry Yes No Yes No
Audiometry Yes No Yes No
G6PD Yes No Yes No
FURTHER INVESTIGATIONS (only if requested by the Company)
Treating specialist/doctor report requested Yes No
(Consider for all unstable, active medical issues, all psychiatric/psychological issues, any condition requiring continuous specialist review)
Medical issues arising through the examination process that may have an impact on suitability for assignment ideally should be alerted to the organisation.
of 12The Travel Doctor-TMVC Medform 1 Standard Pre-Assignment Medical AssessmentVersion 3 Revised 03/2016 11
Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
SUMMARY & RECOMMENDATIONS
For attention of
Company
Re The Travel Doctor-TMVC Standard Pre-Assignment Medical Assessment for
Candidate’s full name (Mr/Mrs/Ms/Dr/Prof) Date of birth (dd/mm/yy) Destination and duration Date of examination (dd/mm/yy) Location of assessment
RECOMMENDATION (select one)
1. Suitable for proposed placement & assignment. No medical issues present.
2. (a) Suitable for proposed placement and assignment. Minor medical issues identified are considered stable and would not preclude successful assignment.
2. (b) Suitable for proposed placement, but noting a significant pre-existing medical condition is present, which would not preclude successful assignment provided the following is accounted for:
Continued supply of medications is arranged Medical review or testing is required during period of assignment Other – please specify: The development of a Health Issue Management Plan by the treating practitioner has been advised.
3. Recommendation pending health issue under review. Either a newly identified active medical problem, or an unstable pre-existing condition has been identified. The candidate may be suitable for assignment after appropriate assessment and management. The following action has been recommended:
a. Follow-up required with local doctor for assessment and treatment b. Specialist opinion or management required c. Laboratory reports required (Complete section below)
4. Candidate considered unsuitable for proposed assignment.
Name & professional qualifications of Medical Examiner
Address Postcode
Signature and date (dd/mmyy) Practice Stamp
Date of review at Travel Doctor
(Only required if Recommendation 3 above applies)
Final Recommendation (select one)
Suitable Unsuitable for proposed assignment
Doctor’s name Signature and date (dd/mmyy)
Standard Pre-Assignment Medical Assessment
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Client name
Date of birth
Medform 1 Standard Pre-Assignment Medical Assessment
VACCINE & SERVICE SUMMARY (This page to be used optionally - according to client’s requirement)
Candidate’s name Destination location Date of Travel Doctor initial consultation & preparation
Vaccine
Indicated for proposed location
per agreed recommendations
Previous immunity Vaccine given, type, date
Doses/visits required
(e.g. 3 does over 3 visits)
Polio Yes No Yes No
ADT Yes No Yes No
MMR Yes No Yes No
Varicella Yes No Yes No
Influenza Yes No Yes No
Hep A Yes No Yes No
Typhoid Yes No Yes No
Hep B Yes No Yes No
JEV Yes No Yes No
Rabies Yes No Yes No
YF Yes No Yes No
Men Yes No Yes No
TST Yes No Yes No
Pneumococcal Yes No Yes No
Other Yes No Yes No
Has detailed information about malaria been provided? Yes No
Antimalarials required? Yes No
If yes, detail type & amount Has medical kit been explained & provided? Yes No
Has the “Health Guide for International Travel” booklet been provided? Yes No
Other specific issues discussed include Was any laboratory testing required to establish suitability? Yes No
If yes, give details Is blood group known? Yes No
If yes, give details