Purpose: to provide a detailed outline of the worker’s medical history and to make the practitioner aware of anything to look out for or perhaps further investigate during the medical assessment.
Who can complete: registered or enrolled nurse, doctor or trained allied health professional (occupational therapist, exercise physiologist, physiotherapist).
Time to complete: 5 – 10 minutes
When to Immediately Cease Testing:
There are a variety of reasons we cease testing however it is ONLY the cardiac and respiratory demanding tasks (spirometry, step testing, lifting and carrying tasks) that we cease in medical assessments and functional assessments when/if we cease for any reason.
Please see some of the reasons for ceasing the functional or spirometry
if heavily pregnant,
recently injured to the extent that it prevents a safe test or had a significant surgery in the past 6 weeks
spirometry contraindications. (please see Spirometry section, page 12.)
Blood pressure or heart rate protocol thresholds reached
Positive to any question in section 1-4 on Physical Activity Readiness Questionnaire (PAR-Q) in functional forms
The Medical History is completed before the assessment either with an online link/Carelever Forms or on paperwork before the assessment. The practitioner should then review the information with the applicant during their appointment and ask follow-up questions where appropriate.
PLEASE NOTE: Every “yes” ticked box should be followed up with a corresponding note from the examiner. For example: “Have you ever been admitted to a hospital?” – Yes, was admitted in 2008 with a case of measles. Nil issues since.”
As per example, the minimum response should include the type of surgery/injury/condition, dates (of diagnosis, or if regarding medication, how long have they been using?), and treatment outcomes (e.g. ongoing or full recovery?).
Each medical will have a slightly different Medical History paperwork, depending on the company request and their proposed job role, and they all vary in length and detail.