On-Arrival Refugee Health Assessment

**On-Arrival Refugee Health Assessment** **General Information:** [State patient’s name, DOB, age, and sex] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State address and contact details if provided] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention emergency contact name, relationship, and phone number] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention Medicare or health care card details if available] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State if interpreter required and preferred language] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention if interpreter was used during consultation and interpreter’s gender preference if specified] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention who referred the patient and reason for referral] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State who completed the assessment (GP, nurse, etc.) and date] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Migration History:** [State country of birth and ethnicity] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention countries or places of transit, including refugee camps or detention centres] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention date of arrival in Australia and current visa type] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State if visa was granted within the last 12 months] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Social History:** [Describe housing situation: temporary or permanent, and duration at current address] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State household composition, family members in the home, and significant relatives overseas] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention employment status, educational enrolment, or previous occupation and qualifications] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention language literacy or any communication challenges] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Medical History:** [List current patient concerns or symptoms] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State current and previous medications, including herbal, traditional or over-the-counter treatments] (Only include if explicitly mentioned in transcript. Write in full sentences.) [List allergies and reactions] (Only include if explicitly mentioned in transcript. Write in full sentences.) [If no allergies, state “No known allergies.” only if explicitly mentioned.] [Mention family medical history including hereditary or chronic conditions] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention any significant injuries, accidents, or hospitalisations] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention history or contact with infectious diseases such as TB, malaria, hepatitis, HIV, or parasites] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention immunisation history, including documentation reviewed and vaccines received or due] (Only include if explicitly mentioned in transcript. Write in full sentences.) [If a catch-up immunisation plan is developed, state that and note consent obtained] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Chronic and Non-Communicable Diseases:** [Mention any known chronic diseases such as diabetes, heart disease, thyroid issues, kidney disease, or cancer] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention any physical or mobility limitations] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State smoking status, alcohol use, or use of other substances such as betel nut or khat] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention level of physical activity and dietary habits if discussed] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention any vision, hearing, or dental concerns] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Children and Adolescents (if applicable):** [State if child’s growth and development were assessed and any concerns noted] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention if Maternal and Child Health services are involved and referrals made] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Describe education status, including schooling history or gaps] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention behavioral or developmental concerns at home or school] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Women’s Health (if applicable):** [State pregnancy status and gestation if pregnant] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention breastfeeding status and past pregnancies/births] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention cervical or breast screening status and year completed] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention any discussion or findings related to female circumcision or intimate partner violence] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Sexual Health:** [Mention if contraception is currently used or previously used] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State if STI screening has been offered or completed] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention any reported symptoms or risks related to sexual health] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Psychosocial History:** [Mention settlement challenges such as housing, finances, or family separation] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention support systems such as friends, family, or community groups] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention appetite, sleep, energy, concentration, and mood changes] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State if mental health concerns or referral needs were identified] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention any history or effects of trauma, torture, or conflict exposure if raised by patient] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Physical Examination:** [State height, weight, BMI, and blood pressure] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention any abnormalities noted on general examination] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Describe findings on skin, ENT, dental, respiratory, cardiovascular, abdominal, neurological, or other systems] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention vision and hearing screening results if performed] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Screening and Investigations:** [List investigations ordered or reviewed, including blood tests, serology, or imaging] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention any specific tests such as Hepatitis B/C, HIV, malaria, TB, vitamin D, or ferritin] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention stool or urine tests if applicable] (Only include if explicitly mentioned in transcript. Write in full sentences.) **Management Plan and Referrals:** [List identified problems or needs and management actions taken] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State referrals made (e.g. dental, optical, mental health, women’s health, refugee health nurse, allied health)] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention if follow-up appointments or reminder systems arranged] (Only include if explicitly mentioned in transcript. Write in full sentences.) [State if consent obtained to share information with other providers] (Only include if explicitly mentioned in transcript. Write in full sentences.) [Mention if GP Management Plan, Team Care Arrangement, or Mental Health Plan created] (Only include if explicitly mentioned in transcript. Write in full sentences.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or continuing care. Use only the transcript, contextual notes, or clinical note as reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, do not state it has not been mentioned — simply omit the placeholder or leave it blank. Use as many lines or bullet points as needed to capture all relevant information.)