Medicare Health Assessment for Refugees and other Humanitarian Entrants 

Use of a specific form to record the results of the health assessment is not mandatory but the health assessment should cover the matters listed below.  

Patient’s Name ……………..………………….……

Mother/Father/Guardian  (For children)
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Proposer (if applicable)………………………………..

Current contact details
Address 
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Phone ………………………….………………………
Email …………………………………………………..	Male  □  Female  □  DOB …../…../…..  or Age …...

Nationality ………………………………….……………
English Skills      Needs interpreter   Yes  □  No  □ 
Interpreter name/s  …………………………………….
Language/s spoken (in order of preference)
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The Doctors’ Priority Line 1300 131 450 provides priority access to fee-free telephone interpreting services for doctors 	

Patient Consent
Explanation of health assessment given         Yes □
Patient consent for health assessment given  Yes □
Date consent was given:                          __/__/____	
Consent given for information to be collected by:
Health Worker  □                                      
Practice Nurse  □
Other                □   please specify ………………………………                                   
	
Proof provided of eligible visa status (see list below)
Eligible Visa Categories:
□   200   Refugee                                               	□   070   Bridging (Removal Pending)	
□  201   In-country Special Humanitarian            	□   695   Return Pending	
□  202   Global Special Humanitarian                  	□   866   Protection	
□  203   Emergency Rescue                                 	□   786   Temporary (Humanitarian Concern)	
□  204   Woman at Risk                                       		

Migration History 
Country of Birth ……………………………………..       Ethnicity (if different) ……………………………………….

Countries/places of transit
Country:                                                                        Dates:
Country:                                                                        Dates:
Country:                                                                        Dates:
□  Refugee Camp/s      □  Detention Centre/s  
Arrival date in Australia: ……………………………………..  (provide proof)

HEALTH ASSESSMENT SUMMARY	
The health assessment should be undertaken in a culturally sensitive manner that is appropriate to the needs of the patient

PATIENT’S OVERALL HEALTH STATUS
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HEALTH ISSUES IDENTIFIED AND DISCUSSED WITH PATIENT
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Tests undertaken as CLINICALLY indicated, results and what they mean 	
TEST	RESULTS AND WHAT THEY MEAN	

		

		

RECOMMENDED INTERVENTION …………………………………………………………………………………
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MEDICAL HISTORY 

Patient history
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Pre-departure Medical Screening
Ask for the patient’s health manifest if available. This contains information about pre-migration health screening/treatment and health undertaking.
Pre-migration health screening      □   Yes      □   No      □   Unknown
Pre-migration health treatment      □   Yes      □   No      □   Unknown
If yes, note health treatment:………………………………………………………………………………………….…
Health undertaking        □   Yes      □   No      □   Unknown
If yes, note follow-up:………………………………………………………………………………………………….….

Date of Health undertaking (if known):……………………   Service provided by Dr:………………………………

CURRENT HEALTH ISSUES	
CURRENT RISK FACTORS	

		

		
		
Family history of chronic disease
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Other relevant family history
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Chronic conditions
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Allergies/Drug Intolerance
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Current medications 
(including prescription and over the counter and supplied by doctor without prescription)
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Nutritional assessment 
(consider malnutrition, vitamin deficiency or anaemia)
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Immunisation status (referring to current age/sex schedule)
•	For children consider full course and include on the Australian Child Immunisation Register
•	For teenagers consider measles, mumps and rubella vaccine, Hepatitis B, Meningococcal C
•	For adults consider serology and booster.	
TYPE	DATE	TYPE	DATE	

				

PSYCHOLOGICAL HISTORY 

trauma history (history of incarceration, family separation, torture)
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Mood (consider depression, post traumatic stress disorder, survivor guilt)	

IDENTIFIED ISSUES	
ACTION	

		
PHYSICAL EXAMINATION 
Temperature:........  Weight:…..…  Height:..……  BMI:..……  Percentile Chart for children:........	
IDENTIFIED ISSUES	ACTION	

		

Cardiac Examination             Blood pressure: …………  Pulse rate and rhythm:   Normal      Abnormal	
IDENTIFIED ISSUES	ACTION	

		

Respiratory and abdominal examination           	
IDENTIFIED ISSUES	ACTION	

		

Gums and dentition (consider caries, gum disease and decreased dentition)            	
IDENTIFIED ISSUES	ACTION	

		

Ear and hearing	 	
IDENTIFIED ISSUES	ACTION	

		

Visual acuity	
IDENTIFIED ISSUES	ACTION	

		

Other injuries or scars	
IDENTIFIED ISSUES	ACTION	

		

Investigations if clinically indicated 

Investigation	Tests Done	Tests Ordered	Arrangements (e.g. referrals)	
Iron deficiency	□	Date: . . . / .. . . /. . . . . 
		
Lipids	□	Date: . . . / .. . . /. . . . . 		
Glucose	□	Date: . . . / .. . . /. . . . . 		
Hepatitis/Rubella serology	□	Date: . . . / .. . . /. . . . . 		
Urine (Urinary tract infection, Chlamydia with pregnancy)	□	Date: . . . / .. . . /. . . . . 		
Faecal examination for parasites	□	Date: . . . / .. . . /. . . . . 		
Serum Vitamin D	□	Date: . . . / .. . . /. . . . . 		
HIV	□	Date: . . . / .. . . /. . . . . 		
Chest X ray	□	Date: . . . / .. . . /. . . . . 		
Mantoux skin test for Tuberculosis	□	Date: . . . / .. . . /. . . . . 		
Other: 

Advice and Information to the Patient 

Health Issues identified and discussed with patient
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Recommendations and advice given to the patient
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Referrals
□ Surgical	…………………………………	□ Maternal/Child health	…………………………………	
□ Dental	…………………………………	□ Obstetrics	…………………………………	
□ Optometry 	…………………………………	□ Gynaecology	…………………………………	
□ Audiometry	…………………………………	□ Allied Health	…………………………………	
□ Mental Health	…………………………………	□ Other	…………………………………	

Next appointment with doctor:	
Date:  …../…../…..	
GP:  Dr. ……………………………………….	GP’s signature  ……………….…………….	Date:  …../…../…..