standard pre-assignment medical assessment non... · standard pre-assignment medical assessment...

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)


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


Client name

Date of birth


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


Client name

Date of birth


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


Client name

Date of birth


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?


Client name

Date of birth


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.


Client name

Date of birth


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?


Client name

Date of birth


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


Client name

Date of birth


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)


Client name

Date of birth


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.


Client name

Date of birth


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


Client name

Date of birth


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

standard pre-assignment medical assessment non... · standard pre-assignment medical assessment...

Documents