On-Arrival Refugee Health Assessment

**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.