DET Medical Assessment - IBAC

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DET Medical Assessment - IBAC

Comments
This field is for validation purposes and should be left unchanged.
Consent*
1) I give permission for the assessor to conduct a DET Medical assessment, to determine and document the physical capacity demonstrated at the time.

2) I am aware that I will not be required to perform and activities / assessments that I do not feel comfortable performing. If I choose to not perform a task, the reason provided will be documented in the reporting of results.

3) I am aware that during the assessment, I may cease performing a required task should I feel incapable of completing such and/or concerned of my health and safety.

4) I am aware that a DET Medical assessment task may be ceased at the discretion of the assessor at any stage, if the performance of the task is deemed unsafe.

5) I am aware that I should advise the assessor immediately should I experience difficulties with any tested health assessment tasks.

6) I declare that all the information provided in the medical consent form and during the performance of the assessment is an accurate representation of my medical / functional capability at the time.

7) I give permission for the assessor to release information to Recovery Partners and the referrer regarding the results of the assessment.

8) I agree that providing an electronic signature is a sufficient means to indicate my understanding of the DET Medical assessment requirements, and that I have provided an accurate representation of my medical background / capacity to the best of my knowledge.

I agree to undertake a DET medical assessment examination with recovery partners. The examination will include medical testing, strength and flexibility testing, cardiovascular (fitness) testing, injury screening, postural tolerances and vision testing.

I agree to the information contained in this document being used to determine my current health status and personal safety requirements and my ability to perform the functional requirements of the role for which I am being assessed. The answers given to the below questions are true and correct to the best of my knowledge.

I acknowledge that I have read and agree to the above, and therefore give consent to all terms.
Print Name*
Date*
Signature*
Your Name
Your Name
Your Name
First Name*
Last Name*
Date of Birth*
Gender*
Do you predominately use your left / right or both hands to complete daily activities [i.e. writing].*
- Left hand
- Right hand
- Both hands
Have you had any diagnosed cardiovascular conditions in the past that have been resolved [i.e. including and not subject to high blood pressure, heart problems, stroke, peripheral disease].*
- Yes
- No
Are you currently diagnosed with any cardiovascular conditions [i.e. including and not subject to high blood pressure, heart problems, stroke].*
- Yes
- No
Has any member of your family [mother, father, brother, sister] had a heart attack or stroke before the age of 55 years?*
- Yes
- No
If yes, please describe including the treatment plan [i.e.medications]:
Have you had any diagnosed metabolic conditions in the past that have been resolved [i.e. including and not subject to high cholesterol, diabetes, liver and kidney disease]*
- Yes
- No
Are you currently diagnosed with any metabolic conditions [i.e. including and not subject to high cholesterol, diabetes, liver and kidney disease].*
- Yes
- No
If yes, please describe including the treatment plan [i.e.medications]:
Have you had any diagnosed neurological conditions in the past that have been resolved [i.e. including and not subject to epilepsy, multiple sclerosis, cerebral palsy, Alzheimer’s].*
- Yes
- No
Are you currently diagnosed with any neurological conditions [i.e. including and not subject to epilepsy, multiple sclerosis, cerebral palsy, Alzheimer’s].*
- Yes
- No
If yes, please describe including the treatment plan [i.e.medications]:
Have you been diagnosed with any psychological condition[s] that have been resolved [i.e. including and not subject to depression, anxiety, post-traumatic stress disorder].*
- Yes
- No
Are you currently diagnosed with any psychological conditions [i.e. including and not subject to depression, anxiety, post-traumatic stress disorder].*
- Yes
- No
If yes, please describe including the treatment plan [i.e.medications]:
Have you been diagnosed with any endocrinological condition [i.e. including and not subject to hyper-thyroid, hypo-thyroid, type 1 diabetes].*
- Yes
- No
If yes, please describe including the treatment plan [i.e.medications]:
Have you had any diagnosed respiratory condition in the past that have been resolved [i.e. including and not subject to asthma, chronic obstructive pulmonary disease].*
- Yes
- No
Are you currently diagnosed with any respiratory conditions [i.e. including and not subject to asthma, chronic obstructive pulmonary disease].*
- Yes
- No
If yes, please describe including the treatment plan [i.e.medications]:
Have you been previously or currently diagnosed with any of the following injuries:*
- Neck
- Shoulder
- Hip
- Knee
- Lower Back
- Soft tissue [i.e. muscle, ligament and tendons]
- Bone fracture/break
If yes, please describe including the treatment plan [i.e.medications]:
Have you had a previous physical or psychological injury under any workers compensation scheme?*
- Yes
- No
Have you ever been diagnosed with any form of degenerative joint conditions, including, but not limited to Osteoarthritis or Rheumatoid arthritis?*
- Yes
- No
If yes, please describe.
Have you been diagnosed with any vision impairment and require the use of glasses?*
- Yes
- No
Have you been diagnosed with any hearing impairment and required the use of aids?*
- Yes
- No
If yes, please describe including any current aids:
Please indicate if your vaccinations are up to date for:
- Select All
- Tetanus
- Diphtheria
- Whooping Cough
- Measles/Mumps
- Chicken Pox
- Hepatitis B
- Fully Covid-19 Vaccinated
Do you consume alcohol on a frequent basis?*
- Yes
- No
If yes, how often do you consume alcohol?
- Select All
- Less than once per week
- Once per week
- Average 1-2 days per week
- Average 3-4 days per week
- Average 5-6 days
When you consume alcohol, how many standard drinks may you have?
- Select All
- 1-2 standard drinks
- 3-4 standard drinks
- 5-8 standard drinks
- >8 standard drinks
To the best of your knowledge, do you believe you may be pregnant?*
- Yes
- No
Do you frequently experience shortness of breath and/or abnormal chest pain during activities of daily living?*
- Yes
- No
Do you experience swelling in your lower limbs during activities of daily living?*
- Yes
- No
Are you currently taking any medication that may impact your ability to complete the assessment and / or the inherent requirements of the role?*
- Yes
- No
If yes to any of the above, please describe:
You will be taking part in a DET Health assessment that will be physically demanding. To the best of your knowledge do you have any medical condition(s) that may affect your ability to perform these assessments?*
- Yes
- No
To the best of your knowledge, do you have any medical condition(s) that may affect your ability to complete/participate in the DET health assessments?*
- Yes
- No
If yes to any of the above, please describe:

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DET Medical Assessment - IBAC

DET Medical Assessment - IBAC