**On-Arrival Refugee Health Assessment**
**General Information:**
Patient's name: Fatima Ali, DOB: 12/03/1988, Age: 36, Sex: Female.
Address: 12 Acacia Street, Anytown, NSW 2000. Contact number: 0412 345 678.
Emergency contact: Ahmed Ali (Husband), phone number: 0498 765 432.
Medicare card details: 1234567890123.
Interpreter required: Yes, Arabic. Interpreter used during consultation: Yes, male interpreter.
Referred by: Refugee Resettlement Agency, reason for referral: Comprehensive health assessment.
Assessment completed by: Dr. Thomas Kelly, GP. Date: 1 November 2024.
**Migration History:**
Country of birth: Syria. Ethnicity: Syrian.
Countries of transit: Lebanon, Turkey. Refugee camp: Zaatari Refugee Camp (Jordan).
Date of arrival in Australia: 15/09/2024. Current visa type: Humanitarian Visa.
Visa granted within the last 12 months: Yes.
**Social History:**
Housing situation: Permanent. Duration at current address: 6 weeks.
Household composition: Husband and two children. Family members overseas: Parents and siblings in Syria.
Employment status: Unemployed. Previous occupation: Teacher.
Language literacy: Arabic and English (limited).
**Medical History:**
Current patient concerns or symptoms: Chronic cough, anxiety, and headaches.
Current and previous medications: Salbutamol inhaler (as needed), Paracetamol (as needed). Herbal treatments: None.
Allergies: Penicillin.
Family medical history: Father with hypertension, mother with diabetes.
Significant injuries, accidents, or hospitalisations: None.
History or contact with infectious diseases: Contact with TB in refugee camp.
Immunisation history: Reviewed immunisation records, vaccines up to date.
**Chronic and Non-Communicable Diseases:**
Chronic diseases: Asthma.
Physical or mobility limitations: None.
Smoking status: Non-smoker. Alcohol use: Occasional. Other substances: None.
Level of physical activity: Moderate. Dietary habits: Healthy diet.
Vision, hearing, or dental concerns: None.
**Children and Adolescents (if applicable):**
Child’s growth and development assessed: Yes, concerns noted regarding child's delayed speech development.
Maternal and Child Health services: Referral made to MCH nurse.
Education status: Children enrolled in primary school.
Behavioral or developmental concerns: Child has some behavioral issues at school.
**Women’s Health (if applicable):**
Pregnancy status: Not pregnant.
Breastfeeding status: Not applicable.
Cervical or breast screening status: Cervical screening due.
Female circumcision or intimate partner violence: No discussion.
**Sexual Health:**
Contraception: Not currently used.
STI screening: Offered and declined.
Symptoms or risks related to sexual health: None reported.
**Psychosocial History:**
Settlement challenges: Housing and financial difficulties.
Support systems: Husband, community groups.
Appetite, sleep, energy, concentration, and mood changes: Anxiety and sleep disturbance.
Mental health concerns: Anxiety. Referral to a psychologist.
History or effects of trauma, torture, or conflict exposure: Witnessed violence in Syria.
**Physical Examination:**
Height: 165cm, Weight: 68kg, BMI: 25, Blood pressure: 130/80 mmHg.
Abnormalities on general examination: Mildly anxious.
Skin: Normal. ENT: Normal. Dental: Normal. Respiratory: Mild wheezing on auscultation. Cardiovascular: Normal. Abdominal: Normal. Neurological: Normal.
Vision and hearing screening results: Not performed.
**Screening and Investigations:**
Investigations ordered: Full blood count, chest X-ray, Mantoux test, and mental health screening.
Specific tests: Hepatitis B/C, HIV, malaria, TB.
**Management Plan and Referrals:**
Identified problems or needs and management actions taken: Asthma management, anxiety management, TB screening, and mental health support.
Referrals made: Psychologist, respiratory specialist, and refugee health nurse.
Follow-up appointments or reminder systems arranged: Asthma review in 2 weeks.
Consent obtained to share information with other providers: Yes.
GP Management Plan, Team Care Arrangement, or Mental Health Plan created: Mental Health Plan created.
