centrelink	Medical Certificate	

Patient's details	Office use only--CRN	
Family name	  <<Patient Demographics:Surname>>	  Home Address	  <<Patient Demographics:Address Line 1>>	
				
First name	  <<Patient Demographics:First Name>>		  <<Patient Demographics:City>>	
				
Second name	  		  <<Patient Demographics:State>>	<<Patient Demographics:Postcode>>	
				
Date of Birth	  <<Patient Demographics:DOB>>			
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 /Related 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 to work from date>> 	
to	
<<Patient unfit to work to date>>	

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

Can the patient do any other work for 8 hours or more per week?	
<<Patient can do other work for 8+ hours 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 other factors impacting work/study>>	

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

Qualifications	
 <<Doctor:Qualifications>>	
Provider No	
<<Doctor:Provider Number>>	

Surgery name	
  <<Practice:Name>>	

	

Adddress	
     <<Doctor:Address Line 1>> <<Doctor:City>>  <<Doctor:Postcode>>	

	

Phone Number	
  <<Doctor:Phone>>	

Signature	

	

Date	

  <<Miscellaneous:Date (short)>>