We comply with the Privacy Act 1988 in relation to the collection, use and disclosure of your personal information.
Collection
We will collect information that is necessary to properly advise and treat you. Such information may include, but is not limited to:
- A full medical history, including where clinically relevant a family medical history.
- Ethnicity.
- Name, address, telephone number, Medicare and Centrelink details.
- Billing and account details.
- Copy of driver’s licence.
The information will normally be collected directly from you. There may be occasions when we will need to obtain information from other sources or health care providers. In emergency situations we may need to collect personal information from relatives or other sources where we are unable to obtain your prior consent. Both our practice staff and Medical Practitioners may collect this information and have access to the information in order to carry out their duties. All practice staff are aware that a breach of patient confidentiality is considered a dismissible offence.
Use and Disclosure
With your consent, we will use and disclose your information for purposes such as:
- Account keeping and billing purposes, including debt collection services.
- Referral to another medical practitioner or health care provider for advice or treatment.
- Sending samples for analysis.
- Management purposes of our practice, including Quality Assurance, Practice Accreditation and complaint handling.
- Meeting obligations of notification to our medical defence organizations or insurers.
- When legally required to do so, such as court requests, mandatory reporting requirements, diagnosis of certain notifiable diseases and Workers Compensation compliance.
- Complying with the requirements of the National Childhood Immunization Register.
In relation to medicals and consultations procured or requested by our overseas clients, we may disclose your personal information to these clients in their countries of operation. We do not otherwise disclose your personal information to overseas recipients. In the event that we would like or are required to do so, we will obtain your consent.
Our Privacy Policy
Our Privacy Policy contains information about the collection, use and disclosure of your personal information. This includes information about how you may: access your personal information; seek the correction of such information; and/or complain about a breach of the privacy laws that bind us (and how we will deal with such a complaint). Our Privacy Policy is available on our website or on request.
Authorisation and Consent
Please read the following and sign where indicated:
I provide consent for the collection, use and disclosure of my personal information as outlined above and in accordance with the Privacy Policy.
In the case of a work-related consultation or service only (including, but not limited to, pre-employment medical assessments and Workers Compensation medical assessments), I hereby authorise the release of any information acquired, collated or ascertained as a result of the examination and consultation (including a copy of my driver’s licence) to my employer, prospective employer or their authorised representative. I also acknowledge that the findings of this examination may be used by my employer, prospective employer or their authorised representative in relation to my employment. I further acknowledge that information obtained about my medical history and condition from any previous medicals and/or other consultations may be used as part of the current assessment.
| Surname | First Name | ||
| Address | Post Code | ||
| Home Phone | Mobile Phone | ||
| Date of Birth | Gender | ||
| Family Doctor | Contact Person | ||
| Proposed Employer | Site Name | ||
| Assessor Name | Clinic | ||
| Proposed Role | Contact Person | ||
| Company | No of Years | Job Title | Chemical Exposure |
|---|---|---|---|
| 1. | |||
| 2. | |||
| 3. | |||
| 4. |
| Q1. Are you currently being treated for any medical condition? | Q8. Have you ever had an x-ray, CT, ultrasound or MRI scan? | ||
| Q2. Do you expect to consult a doctor or expect to receive any treatment in the near future? | Q9. Have you ever been refused life/disability insurance, military service or employment for medical reasons? | ||
| Q3. Is there any history of serious illness or disease in your family? | Q10. Have you visited a therapist e.g. chiropractor, physiotherapist, osteopath etc. in the last year? | ||
| Q4. Have you ever been admitted to hospital? | Q11. Have you taken any medications in the last month? | ||
| Q5. Have you had time off work in the last 2 years for illness or injury? | Q12. Have you ever been exposed to toxic substances or environmental hazards? | ||
| Q6. Have you ever had a Workers Compensation Claim or any work related illness or injury? | Q13. Have you ever had trouble wearing (PPE) personal protective equipment, safety equipment or breathing apparatus? | ||
| Q7. Do you have a current Workers Compensation Claim or any work related illness or injury? | Q14. Is there any other condition that may impact on your ability to safely perform the duties of your job? |
If you answered ‘Yes’ to any of the above please provide details:
Dr to provide comments for any ‘Yes’ responses: (reference Q No.)
| Q15. Crouching / bending / kneeling | Q20. Standing for 2 hours or more | Q25. Confined spaces or working at heights | |||
| Q16. Running 100 metres | Q21. Sitting for 2 hours or more | Q26. Shift work / sleep | |||
| Q17. Walking on uneven ground | Q22. Climbing stairs/ladders | Q27. Working in hot/cold extremes | |||
| Q18. Turning your head rapidly | Q23. Using hand tools | Q28. Repetitive movement of hands or arms | |||
| Q19. Concentrating on a task | Q24. Gripping firmly with both hands | Q29. Understanding English (incl reading signs) |
If you answered ‘Yes’ to any of the above please provide details:
Dr to provide comments for any ‘Yes’ responses: (reference Q No.)
| Q30. Lung/Breathing problems | Q40. Blood pressure/Heart problems | Q50. Skin disorders/Dermatitis | |||
| Q31. Asthma/Hay fever/Allergies | Q41. Rheumatic Fever | Q51. Hernia |
If you answered ‘Yes’ to any of the above please provide details:
Dr to provide comments for any ‘Yes’ responses: (reference Q No.)
| Q60. Do you engage in regular exercise? (30 mins at least 3x week) | Q63. Do you smoke? If yes, what age did you start How many packs a year? | ||
| Q61. Do you take illicit Drugs? | Q64. Have you ever smoked? If yes what age did you start? What age did you stop? | ||
| Q62. Do you drink more than 2-3 standard drinks of alcohol per day? If yes, how many drinks do you have a day? |
If you answered ‘Yes’ to any of the above please provide details:
Dr to provide comments for any ‘Yes’ responses: (reference Q No.)
Please read the following and sign where indicated
Declaration – I declare that I have answered the above correctly and completely, to the best of my knowledge. I understand that any false or misleading information may result in disciplinary action, up to and including termination of employment.
Statement authorisation – I hereby authorise the examining doctor to release any information acquired, collated or ascertained as a result of the examination and consultation to my employer, prospective employer or their authorised representative. I also acknowledge that the findings of this examination may be used by my employer, prospective employer or their authorized representative in relation to my employment. I further acknowledge that information obtained about my medical history and condition from any previous medicals and/or consultations may be used as part of the current assessment.
If Yes: provide details
Please return this form to reception when completed
| 1. Height(cm) | 2. Weight(kg) | 3. BMI | |||
| 4. Urinalysis | Blood: Sugar: Protein: |