centrelink	Medical Certificate	

Patient's details	Office use only--CRN	
Family name	  <PtSurname>	  Home Address	  <PtStreet>	
				
First name	  <PtFirstName>		  <PtCity>	
				
Second name	  <PtMidName>		  <PtState>		<PtPostcode>	
				
Date of Birth	  <PtDoB>			
This patient has been my patient since:  	<Patient has been my Patient since>	
A patient of this practice since:  	<Patient has been a patient of this practice since>	

Primary condition 			             Secondary/Related condition(s) 
Diagnosis - Please list the main medical conditions which impact on the patient's capacity to work or study
                    (Primary condition should be the condition with most impact). 
<Primary Condition - Diagnosis>		<Secondary Condition - Diagnosis>	

 Date of onset (if known)	<Primary Condition - Onset Date>	          Date of onset (if known)	<Secondary Condition - Onset Date>	
 Is this condition                                                                              Is this condition       
<Primary Condition - Type>		<Secondary Condition - Type>	

 Prognosis – Please estimate how long the symptom(s) will affect the patient's capacity to work or study.
<Primary Condition - Prognosis>		<Secondary Condition - Prognosis>	
 Symptoms - Please list current symptoms for each condition.
<Primary Condition - Symptoms>		<Secondary Condition - Symptoms>	

 Treatment - Please describe the patient's treatment regime, including past, current and planned treatment.
Past:  <Primary Condition - Past treatment>		Past:  <Secondary Condition - Past treatment>	
Current: <Primary Condition - Current treatment>		Current:  <Secondary Condition - Current treatment>	
Planned: <Primary Condition - Planned treatment>		Planned:  <Secondary Condition - Planned treatment>	
 
Please give details of any other medical conditions which impact on the patient's capacity to work or study.
 <Other medical conditions impacting work/study>

Capacity to work or study
In my opinion the patient is/has been unfit for work/study	

from 	
<Patient Unfit From Date>  	
to	
<Patient Unfit To Date> 	

Can the patient currently undertake their usual work/study?	
<Can Patient do usual work/study?>	

Can the patient do any other work for 8 hours or more per week?	
<Can Patient do any other work for 8hrs+ per week>	

In order to prepare your patient for return to work/study, certain assistance may be offered. Please identify any  factors which may impact on participation.	

<Other Factors impacting participation in work/study>	

		Certification by Medical Practitioner
Doctor's name (printed)	
  <DrName>	

Qualifications	
 <DrQualifications>	
Provider No	
<DrProviderNo>	

Surgery name	
  <Practice>	

	

Adddress	
  <UsrAddress>    <DrPostcode>	

	

Phone Number	
  <DrPhone>	

Signature	

	

Date	

  <TodaysDate>