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Department of Defence- Civilian Non-Operational
Pre-Assignment Medical Assessment
(Medform 1)
PART 1 – QUESTIONNAIRE
To be completed by examinee
Instructions
To your health overseas, it is important for the examining doctor to find out about your past and present health status. The
questions below are designed to pick up specific health problems or concerns and 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).
Examinee identification
 Employee
 Family member
Surname
 Other
Date of birth
Given names
 Male
 Female
Home address
Suburb
Postcode
Telephone home
Telephone work
(
(
)
Fax
(
)
Mobile
)
Email
Overseas Assignment/Reassignment
Position
City
Country
If family member, what is full name of employee
Date of
assessment
Proposed date of
departure from Australia
Length
of stay
Name and Address of General Practitioner (if nominated)
Name
Address
Phone
Suburb & Postcode
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 1 of 15
Client name
Date of birth
PERSONAL STATEMENT




I declare the information provided by me to be full and correct to the best of my knowledge. I understand
the record will be retained in a safe and secure confidential manner.
I understand that a copy of the Summary and Recommendation page only will be given to the Department
of Defence.
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
Signature (Medical examiner)
Date
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 2 of 15
Client name
Date of birth
A. PERSONAL HISTORY
Do you have now, have ever had or have you been treated for any of the following conditions? Please tick Yes
or No in the appropriate boxes.
Yes
1.
1.1
1.2
GASTROINTESTINAL
Dyspepsia, indigestion, acid reflux, gastric, peptic or duodenal ulcer or hiatus
hernia?
Frequent nausea or vomiting or vomiting of blood?
1.6
Passing of blood from the anus or rectum, black motions, haemorrhoids, fistula,
anal fissure or pilonidal sinus?
Liver disease, hepatitis, gallstones or gall bladder disease, biliary colic or
pancreatitis?
1.1 Abdominal pain or colic, irritable bowel disease, recurring diarrhoea or
constipation, ulcerative colitis or Crohn’s disease?
1.2 Unexplained weight loss
1.7
1.3 Hernia, or any abdominal operation?
2.
CARDIOVASCULAR
Heart disease, any investigation of the heart including ECG, stress ECG, echo or
ultrasound or heart operation of any nature?
Any problem with blood pressure including high blood pressure (hypertension), low
blood pressure, postural hypotension, dizziness, loss of balance or fainting?
High blood cholesterol or triglycerides?
1.3
1.4
1.5
2.1
2.2
2.3
2.6
Chest pain or discomfort on exertion, breathlessness or shortness of breath on
exertion?
Palpitations or consciousness of your heart beat, arrhythmia or irregularities of
pulse or heart rate?
Heart murmur or rheumatic fever?
2.7
Swelling of feet, ankles, varicose veins, peripheral vascular disease?
2.8
Any other condition of blood vessels (eg arteritis)?
3.
RESPIRATORY
Chronic or persistent cough, coughing up blood or phlegm?
2.4
2.5
3.1
3.3
Bronchitis, pneumonia, pleurisy, fluid on the lung, emphysema or chronic
obstructive airways disease
Pneumothorax (collapsed lung)
3.4
Tuberculosis or positive Mantoux test for whatever reason?
3.5
Asthma, wheezing, use of inhaler or “puffer”?
3.6
Any other lung disease or chest complaint or problem with breathing?
4.
MUSCULOSKELETAL
4.1
4.3
Neck pain/ injury, back pain/ injury or history of strain “whiplash” injury or history or
vertebral disc disorder?
Stiff or painful joints, arthritis, gout, polyarthritis, osteoarthritis or rheumatoid
arthritis?
Polio, paralysis or muscle weakness, limitation of movement or irregularity of gait?
4.4
Repetitive strain injury (RSI) or occupational overuse syndrome?
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)?
3.2
4.2
No
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 3 of 15
Client name
Date of birth
5.
EYE, EAR, NOSE & THROAT
5.1
5.2
Any eye disorder or operation, including need for glasses or contact lenses, radial
keratotomy, or laser surgery?
Colour perception problems?
5.3
Any disorder of speech?
5.4
5.5
Persistent ear or sinus problems, ear infections, or perforated ear drum or
operation?
Deafness or poor hearing?
5.6
Tinnitus (ringing in the ears), dizziness or loss of balance?
5.7
Nasal obstruction, allergy, hayfever or allergic rhinitis?
5.8
Motion sickness?
6.
BLOOD, ENDOCRINE AND IMMUNITY
6.1
Tiredness, lethargy, investigations for anaemia or leukaemia?
6.2
6.3
Any blood disorder, bleeding problem, clotting disorder, DVT or pulmonary
embolism (clot travelling to the lung)?
Have you ever had a blood test for HIV?
6.4
Any disorder resulting in reduced immunity?
6.5
Thyroid disorder or surgery?
6.6
Diabetes or abnormal glucose metabolism?
6.7
Significant alteration in weight over the last 12 months?
6.8
6.9
Any abnormality of the immune system, or any significant infectious disease that
required prolonged convalescence? (eg glandular fever, chronic fatigue syndrome)
A blood transfusion?
7.
GENITO-URINARY SYSTEM
7.1
Difficulty or pain passing urine, blood in the urine or abnormal urinary tests?
7.2
Do you have to get up during the night to pass urine? If so, how many times?
7.3
7.4
Any kidney or bladder disease or infection (eg cystitis, nephritis, kidney stones),
investigation or operation?
Sexually transmitted diseases?
8.
SKIN
8.1
Any chronic, persistent or intermittent skin condition such as urticaria (hives)
eczema, dermatitis, or psoriasis?
Any skin reactions to occupational contact chemicals or allergic reactions to any
specific agent?
NEUROLOGICAL
8.2
9.
9.1
Yes
9.4
Have you ever had to take medication to relieve symptoms of anxiety, depression,
situational stress or any nervous disorder?
Any history of psychiatric, behavioural or psychological condition or need for
counselling?
Any history of alcohol or drug addiction or any traffic or criminal convictions relating
to alcohol or drugs? Have you ever used or do use intravenous drugs of addiction?
Claustrophobia or fear of flying?
9.5
Difficulty with concentration or memory?
9.6
Post traumatic stress disorder?
9.7
Epilepsy or any type of fit or funny turn?
9.8
Fainting related to injections?
9.9
Frequent or severe headaches, migraine or cluster headaches?
9.2
9.3
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
No
Page 4 of 15
Client name
Date of birth
NEUROLOGICAL continued …
Yes
9.10
Unconsciousness or loss of memory?
9.11
Insomnia or other sleep disorder?
9.12
9.13
Persistent disturbance of sensation such as tingling, numbness or pain, or carpal
tunnel syndrome?
Head injury or concussion?
9.14
Any other neurological disorder?
10.
OTHER
10.1
Any dental problems, dentures or history of restorative dental work?
10.2
Any problems with the last molar teeth (wisdom teeth)?
10.3
Years since last dental check?
10.4
Any form of cancer or tumour, including skin cancer?
10.5
11.
Any other health matter which may be relevant, or that may affect working under
stressful situations particularly in a cross cultural setting?
Any hospitalisation or other medical condition, operations or investigations not
already mentioned?
Any proposal to insure you for life, sickness or disability insurance or
superannuation, accepted on special terms, deferred or declined?
Do you belong to any one of the following HIV/AIDs high risk groups established
by health authorities IV drug user, homosexual or bisexual male, haemophiliac?
Have you ever had any travel-related illness eg malaria, dengue fever, typhoid,
schistosomiasis (bilharzia) or gastrointestinal disease eg giardia
WOMEN ONLY
11.1
Are you pregnant now?
11.2
Do you intend to become pregnant in the next 2 years?
11.3
If you have been previously pregnant, were there any problems?
11.4
Do you have any menstrual problems?
11.5
Do you have a history of endometriosis or polycystic disease of the ovaries?
11.6
Are you prone to vaginal thrush?
11.7
What was the date of your last pap smear?
11.8
Have you ever had an abnormal pap smear?
11.9
Have you ever had a screening mammogram?
11.10
If you have had a mammogram, when was it last done?
11.11
Have you ever been investigated for a breast problem?
11.12
Have you gone through the menopause?
11.13
If you have been through the menopause, what was your approximate age?
11.14
Have you had any other gynaecological or urinary problems or operations?
12.
MEN ONLY
12.1
12.2
Have you ever had or have any testicular problems (eg hydrocoele, varicocoele,
undescended testicles), any operation on the scrotum including vasectomy?
Have you had any genitourinary problem or operation?
12.3
Have you had any problem relating to the prostate?
10.6
10.7
10.8
10.9
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
No
Page 5 of 15
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 and siblings
 High Blood Pressure
 Early Coronary artery disease
< 55 in male, < 65 in female
 Blood or clotting disorder
 High cholesterol
 Other heart condition
 Family inherited disorder
 Stroke
 Hip fracture
DOCTOR’S COMMENTS
 Diabetes
 Breast Cancer
 Bowel Cancer
............................................................................................
State the age and health of your close family members. If they are no longer alive, please note age
and cause of death if known
RELATIVE
Mother
Father
Siblings
AGE
ALIVE
STATE OF HEALTH
AGE
DECEASED
CAUSE OF DEATH
C. MEDICATIONS
Tick if you take medications for any of the following conditions



High Blood Pressure
High cholesterol
Heart condition
 Diabetes
 Epilepsy
 Nervous eg
depression
 Bowel disorder
DOCTOR’S COMMENTS
 Blood thinning
 Other, specify
......................................................................................
Name of medication/s if taking
 Yes
 No
Do you have any allergies to medications (eg penicillin,
sulfa), foods or pollens, grasses etc
 Yes
 No
If yes, please list
 Yes
 No
Do you take any over-the-counter (non prescription)
medications? If Yes, please note
D. ALLERGIES
.................................................................................................
.
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 6 of 15
Client name
Date of birth
E. SMOKING
1.1 Do you currently smoke?
If Yes, how many do you smoke daily
....................................
1.2 Have you smoked in the past?
If yes, how many years and when did you give up?
 Yes
 No
 Yes
 No
F. ALCOHOL HISTORY
How often do you consume alcohol?
 Never consume alcohol
 On 3-4 days per week
 Once per week
 On 5-6 days per week
 On 1-2 days of the 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? ..............................................................
G. LIFESTYLE
1.1 Recreation
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?
.............................................................................................................................................................................
1.2 Nutrition
Are you on a particular diet, e.g. vegan, vegetarian, low saturated fat etc?
 Yes
 No
If yes, please note
................................................................................................................................................................................
................................................................................................................................................................................
Have you ever taken medications for malaria prevention before?
 Yes
 No
If so, which ones and for how long? .............................................................................................................................
Did you experience any special issues with them?
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 7 of 15
Client name
Date of birth
VACCINATIONS
Please tell us about your previous vaccinations. You may need to refer to your vaccine records. You can write
the name of the vaccination of you wish.
Vaccine
Last dose received
(approx)
Comments
Influenza
Polio
Tetanus
Measles
Chicken Pox
Hepatitis A
Full Course complete?
 Yes
 No
Hepatitis B
Full Course complete?
 Yes
 No
Rabies
Full Course complete?
 Yes
 No
Japanese Encephalitis
Full Course complete?
 Yes
 No
Typhoid
Meningitis
Yellow Fever
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.
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 8 of 15
Client name
Date of birth
THIS QUESTION 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 concerns from lifestyle or family history?
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 9 of 15
Client name
Date of birth
PART 2 – MEDICAL
To be completed by examining doctor
The purpose of this health assessment is two-fold. First to ensure the person is fit for the
proposed overseas placement. Second 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 and medications and
malaria prophylaxis completed where necessary.
cm
1. Height
kg
2. Weight
3. BMI
Weight (kg)
Height (m2)
4. Blood pressure
Before
Rest
5. Pulse
After
Rest
Systolic
Diastolic
Repeat after 5 minutes if >130/85
6. Abdominal Girth
cm
7. Urinalysis (please record)
Blood
Sugar
Protein
8. Visual Acuity
Without correction
With correction
R
6
L
6
R
6
L
6
 Normal
9. Colour Perception (Ishihara)
 Abnormal
10. Clinical Evaluation (tick appropriate column)
Abnormal
Not
Exam.
Normal
10.1 Eyes (external)
10.2 Eyes (Fundi)
10.3 Hearing (spoken voice)









10.4 Ears and drums



10.5 Nose and sinuses
(if indicated)



10.6 Mouth, teeth, throat



10.7 Neck and thyroid
10.8 Heart
10.9 Chest and Lungs
10.10 Skin
10.11 Spine















10.12 Psychological



10.13 Abdomen
10.14 Hernial Orifices
10.15 Breasts
10.16 Genitalia
(If indicated by Hx)
10.17 Anus and rectum
(if indicated by Hx)
10.18 Prostate exam
(If indicated by Hx)
10.19 Reflexes
10.20 Peripheral pulses
10.21 Peripheral veins
10.22 Lymph nodes
10.23 Range of Movt
10.24 Muscle Tone and
Power
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
Abnormal
Not
Exam.
Normal




































MEDICAL IN CONFIDENCE
Page 10 of 15
Client name
Date of birth
EXAMINATION COMMENTS AS REQUIRED
Name of medical examiner (block capitals)
Date
Signature
Qualifications
Address
Postcode
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 11 of 15
Client name
Date of birth
MEDICAL INVESTIGATIONS
TEST
REQUESTED
(Y/N)
COMPLETED
(Y/N)
RESULT
Blood Group
Quantiferon-Gold Test
G6PD
Further Investigations (only if approved by Travel Doctor Corporate Medical Services)
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 12 of 15
DEPARTMENT OF DEFENCE CIVILIAN NON-OPERATIONAL PRE-ASSIGNMENT
MEDICAL ASSESSMENT
SUMMARY & RECOMMENDATIONS
For attention of
Re: The Travel Doctor-TMVC Dept of Defence Civilian Non-Operational Pre-Assignment Medical
Assessment forCandidates full name (Mr/Mrs/Ms/Dr/Prof)
Date of birth
Destination and duration
Date of examination
Location of assessment
RECOMMENDATION (select one)
 1. Suitable for proposed placement and 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 (specify:
And
 It is considered that this condition can be suitably managed at the destination, and the
development of a Health Issue Management Plan 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.
b.
c.

Follow-up required with local doctor for assessment and treatment
Specialist opinion or management required
Laboratory reports required
(Complete section below)
4. Candidate considered unsuitable for proposed assignment.
Name & professional qualifications of Medical Examiner
Address
Signature and Date
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
Postcode
Practice stamp
MEDICAL IN CONFIDENCE
Page 13 of 15
Client name
Date of birth
Only required if Recommendation 3 above applies
Date of review at Travel Doctor
Final Recommendation (select one)
Suitable/unsuitable for proposed assignment
Doctor’s name
Signature
Date
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 14 of 15
VACCINE & SERVICE SUMMARY
Candidate’s name
Destination location
Date of Travel Doctor initial consultation and preparation
Vaccine
Indicated for
proposed
location per
agreed
recommendations
(Y/N)
Previous
immunity
(Y/N)
Vaccine
given, type,
date
Doses/visits required (e.g. 3
does over 3 visits)
Polio
ADT
MMR
Varicella
Influenza
Hep A
Typhoid
Hep B
JEV
Rabies
YF
Men
Pneumococcal
Other
Has detailed information about malaria been provided?
 Yes
 No
Antimalarials required
 Yes
 No
If yes, detail type and amount ...............................................................................................................................
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?
If yes, details
 Yes
 No
What is the patient’s blood group?
.................................................................................
Dept Defence Civilian Non-Operational Pre-Assignment Medical Assessment
Revised Nov 2013
MEDICAL IN CONFIDENCE
Page 15 of 15