Absolute Injury Management

Pre-Employment Medical Assessment System

Patient Questionnaire

Complete your health history before your assessment appointment

Clinician Assessment

Complete the clinical examination and generate the assessment report

Admin / Config

Manage client profiles, module settings, and form configurations

New Appointment

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Position Applied For

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Absolute Injury Management

Pre-Employment Medical Assessment — Patient Questionnaire

your prospective employer

Applicant Details

Consent

Work History

Medical History

Respiratory

Sleep & Psych

Conditions

ID Confirmation

Applicant Details

Please complete all fields accurately. This information will be used to identify you throughout the assessment process.

First Name

Surname

Date of Birth

Gender

Mobile Phone

Email Address

Position Applied For

Site / Location

Appointment Date

Appointment Time

Dominant Hand

Authority & Consent

Please read the following carefully before signing.

Patient Consent Signature

I declare that: The information I have provided is true and complete to the best of my knowledge. I authorise Absolute Injury Management to obtain and release my medical information to my prospective employer for the purpose of this assessment only. I consent to proceed with the assessment and confirm there are no reasons I cannot safely participate. I am aware that failure to disclose relevant health information may affect my employment application.

Date

Work History

Please provide your employment history for the past 10 years, starting with the most recent.

1Are you currently employed with this employer?

2Have you ever worked for this employer previously?

Please provide details

3Have you ever worked with substances or in conditions that may have been hazardous to your health? (e.g. asbestos, lead, silica, toxic chemicals, noisy environment)

Please provide details including approximate dates of exposure

4Have you ever had an injury or disease at work, or made a workers compensation claim?

What year and what was it for?

How long were you off work?

Did you return to full normal duties?

Was there a compensation payout?

Any associated psychological difficulties?

Do you currently have an open WorkCover / workers compensation claim?

Please provide details of the open claim

5Do you currently have any work restrictions certified by a doctor?

Please specify restrictions

6Do you have difficulty wearing standard safety equipment / PPE? (e.g. boots, glasses, helmets)

Please give details

Respiratory Health

The following questions are required for the spirometry component of your assessment.

14What are your smoking habits?

If current or ex-smoker: age started / stopped, average per day

22Have you ever been diagnosed with any of the following?

Please provide details for any ticked conditions

Sleep, Fatigue & Wellbeing

These questions help assess fitness for shift work and safety-critical roles.

Epworth Sleepiness Scale — How likely are you to doze in these situations?

Situation	Never (0)	Slight (1)	Moderate (2)	High (3)

Total: answer all 8 questions to calculate

Score ≥10 indicates possible daytime sleepiness requiring further assessment. Minimum score is 8 (all Never).

K10 Psychological Wellbeing Scale — In the past 4 weeks, how often did you feel... (Scored 10–50. Score 10–15: likely well. 16–21: mild distress. 22–29: moderate. 30+: severe.)

Question	None (1)	Little (2)	Some (3)	Most (4)	All (5)

Total: answer all 10 questions to calculate

AUDIT — Alcohol Use Questionnaire

Question	(0)	(1)	(2)	(3)	(4)

Total: answer all 10 questions to calculate

Score 0–7 low risk · 8–12 risky or harmful · 13+ dependence likely

Health Conditions

Have you ever experienced the following? Please answer YES or NO for every item.

Have you had any other illnesses, injuries, or operations not covered above?

Please describe

Are you currently taking any medication (including over-the-counter or vitamins) for more than 2 weeks?

Medication Name

What is it for?

Medication Name

What is it for?

Medication Name

What is it for?

Additional medications or notes

Identity Confirmation

Your photo ID will be verified by the assessor at the clinic before your assessment begins.

Photo Identification

ID Type

ID Number

State of Issue (if applicable)

Expiry Date

Your consent signature was recorded in Step 2. Once you submit, your questionnaire will be ready for your therapist. Please bring your photo ID to the appointment for verification.

Step 1 of 8

Patient

—

DOB

—

Role

—

Classification

Medium

Date

⚑ Review flagged items before starting

▲ collapse

Patient Review

Flagged Responses

Baseline

Vitals & Baseline

Audiometry

Spirometry

Urinalysis

Vision

Musculoskeletal

Range of Motion

Postural Analysis

Special MSK Tests

Grip Strength

Functional

Postural Tolerance

Step Test

Manual Handling

Carrying & Pulling

Climbing / Stepping

Outcome

Key Findings

Fitness Outcome

Assessor Signature

Flagged Patient Responses

Items the patient answered YES to, requiring clinical attention or follow-up probing.

Identity Verification — Complete Before Assessment

ID Type (Patient Provided)

—

ID Number

—

Expiry

—

Therapist ID Verification:

Review each flagged item with the patient before commencing the physical assessment. Add clinical notes as required.

No patient questionnaire loaded

When the patient completes their questionnaire, flagged items will appear here automatically for your review.

For demo purposes, some example flags are shown below.

⚑ Low back injury — previous history

Patient reported: "Lower back disc injury 2021, L4/5, 3 months off work, returned to full duties"

Clinical Notes

Reviewed — asymptomatic

Ongoing symptoms noted

Fully recovered

⚑ Tinnitus — reported

Patient reported: "Ringing in right ear, intermittent, worse after noisy environments"

Pre-existing — audiometry pending

Noise-induced pattern suspected

Vitals & Baseline Measurements

Complete before commencing functional testing. BP >160/100 requires medical clearance to proceed.

If BP exceeds 160/100 mmHg, do not proceed with physical testing. Refer for medical review.

Measurements

Blood Pressure

mmHg

Resting HR

bpm

Height

metres

Weight

BMI

—

kg/m²

Max HR (100%)

—

220 − age (bpm)

85% Max HR

—

aerobic threshold (bpm)

Max MH Test Weight

—

60% body weight (kg)

Audiometry

Pure tone audiometry at 500–8000Hz bilaterally, as per Australian Standard AS/NZS 1269.

Hearing Thresholds (dB HL)

Ear	500 Hz	1000 Hz	1500 Hz	2000 Hz	3000 Hz	4000 Hz	6000 Hz	8000 Hz
Left
Right

% Hearing Loss — Left

% Hearing Loss — Right

Binaural Loss

Otoscopy / Auriscope Findings

Audiometry Interpretation

Normal bilaterally

Mild NIHL — right

Mild NIHL — bilateral

Moderate loss — refer

Consistent with tinnitus

Spirometry

Three acceptable results (within ±5% or 0.2L) to be obtained. Post-bronchodilator testing is only performed where the patient is prescribed bronchodilator medication, or where FEV1 <70% predicted with clinical signs of obstruction.

Post-bronchodilator testing performed? (activate only if patient on bronchodilator meds or FEV1 <70% predicted)

Spirometry Results

Acceptable blows obtained

FEV1 and FVC in litres (L) · PEFR in L/min · FEV1/FVC as ratio · Enter predicted values from your spirometry software

Measure	Measured	Predicted	% Predicted	Post Broncho.	% Predicted	% Change
FEV1 L
FVC L
FEV1/FVC ratio
PEFR L/min

Pattern (auto-selected from values above)

Spirometry Interpretation

Normal

Obstructive — refer

Borderline

Consistent with asthma

Urinalysis

Dipstick urinalysis for blood, protein, and glucose.

Urinalysis Results

Blood

Protein

Glucose

All normal

Trace blood — follow up

Glucose — known DM

Vision & Colour Vision

Snellen visual acuity and Ishihara 24-plate colour vision testing.

Does patient wear glasses or contact lenses?

Visual Acuity

Distance	Unaided R	Unaided L	Unaided Both	Aided R	Aided L	Aided Both
Distance
Near (40cm)

Visual Acuity — Findings

Any visual defects or disease of the eyes?

Normal — unaided

Normal — with correction

Reduced — refer

Colour Vision — Ishihara (14 plates)

Tick plates passed. Note actual response for any incorrect plate.

Normal

Red-green deficiency

Mild difficulty

Range of Motion

Assess all physiological movements through full available range. Pain rated 0–10. Limitation documented with degrees where measurable.

Joint ROM Assessment

ROM Additional Comments

All full range — pain free

Functional range — minor restriction

Postural Analysis

Visual observation in relaxed standing and sitting. Shoulder/scapula includes elevation to assess scapulohumeral and scapulothoracic movements.

Postural Findings

Special Musculoskeletal Tests

Pain rated 0–10. Weakness rated Oxford Scale 1–5. Laxity and restriction documented accordingly.

Grip Strength

Hydraulic dynamometer, Setting 2. Elbow at 90° flexion, arm by side. Three trials each hand.

Grip Strength Results

Right Hand

Trial 1 (kg)

Trial 2 (kg)

Trial 3 (kg)

Average (kg)

% Normative for Age (auto)

Coefficient of Variation (auto, >15% = flag)

Left Hand

Trial 1 (kg)

Trial 2 (kg)

Trial 3 (kg)

Average (kg)

% Normative for Age (auto)

Coefficient of Variation (auto, >15% = flag)

Grip Strength Interpretation

Normal bilaterally

Reduced — right hand

Consistent effort

Postural Tolerance

Each posture sustained for 2 minutes (kneeling: 2 min). Assessment ceases if pain exceeds 0/10 with functional significance, HR exceeds maximum, or safety is compromised.

2-Minute Postural Tests

3-Minute Step Test

300mm step. Metronome at 96 bpm, Up-Up-Down-Down pattern. Lead legs can alternate. Cease if HR limit exceeded.

Fitness Level	Male (bpm)	Female (bpm)	Percentile
Excellent	<71	<97	90th
Good	71–102	97–127	75th
Average	103–117	128–142	50th
Fair	118–147	143–171	25th
Poor	148+	172+	10th

⚠ Results unreliable if patient is on beta-blocker medication (HR response blunted)

Step Test Results

Max HR for Test

—

bpm

Baseline HR

bpm

3-Minute HR

bpm

1-Min Post HR

bpm

Pain Rating

/10

RPE

/10

Result

Completed — good fitness

Average fitness

Ceased — HR limit

Manual Handling — Lifting

Top-Down Protocol: Phase 1 — 1 rep at occasional weight. Phase 2 — 5 reps within 1 min at frequent weight. Constant capacity inferred if Phase 2 complete with 0/10 pain, good technique, HR within limits. Testing ceases if HR exceeds maximum, pain >0/10, or technique is unsafe.

Medium Classification: Medium: Occasional 9–23 kg · Frequent 4.5–11 kg · Constant 0–4.5 kg. Do not exceed occasional weight regardless of demonstrated capacity.

Manual Handling — Carrying & Pulling

Same Top-Down Protocol applies. Carrying: 5 metre bilateral carry from 800mm bench. Pulling: resistance band, walk backward to 2× original length, controlled return.

Climbing / Stepping

Step-up testing at 500mm height. Ladder protocol: 3-point contact maintained throughout ascent and descent. Applicant may use hands for balance on step-up.

Step-Up — 500mm

Occasional (1 rep)

Frequent (5 in 1 min)

Pain (0–10)

Peak HR (bpm)

Knee Control

Movement Pattern

Step-Up Notes

Completed — correct technique

Mild valgus — functional

Ceased — technique

Ladder Climbing — Endurance Protocol

Continuous ascent/descent of 2 steps maintaining 3-point contact. Reps vary by classification: Medium = 20, Heavy = 25, Very Heavy = 30.

Constant reps completed

Pain (0–10)

Peak HR (bpm)

RPE (0–10)

3-Point Contact

Movement Pattern

Result

Ladder Notes

Full capacity — correct technique

Frequent demand — complete

Minor technique note

Ceased — safety

Key Assessment Findings

Summarise the key clinical findings across all sections. This section appears prominently in the report.

Summary of Key Findings

All clear — standard summary

Pre-existing history noted

Capacity with restrictions

Fitness for Capacity Outcome

Select the outcome that best reflects the assessment findings. The employer determines suitability for employment — this assessment provides objective capacity information only.

This assessment provides objective capacity data. Absolute Injury Management does not make employment decisions. The determination of suitability for employment remains the responsibility of the employer.

In the opinion of the assessor, the applicant has:

Demonstrated functional capacity consistent with the role — No restrictions or recommendations

All tasks completed with 0/10 pain, technique within normal limits, and HR within testing parameters throughout.

Demonstrated functional capacity consistent with the role — With recommendations for employer consideration

Capacity demonstrated. The following recommendations are provided for the employer's awareness and consideration in placement planning.

Demonstrated functional capacity consistent with the role — With restrictions identified

Capacity demonstrated within defined parameters. The employer is advised to consider the restrictions noted below when determining placement suitability.

Insufficient capacity demonstrated at this classification level

The applicant did not demonstrate sufficient functional capacity for the assessed classification during this assessment. Further assessment, modified role consideration, or medical review is recommended prior to placement decision.

Recommendations / Restrictions (if applicable)

No restrictions

Pre-existing history — monitor

Lifting restriction

Audiometric surveillance

GP referral recommended

Assessor Declaration & Signature

Complete all fields below. The report will not be generated until this section is complete.

Assessor Details

Assessor Name

Qualification

AHPRA / Registration Number

Assessment Date

Clinic Name

Clinic Address

Clinic Phone

Clinic Email

Assessor Signature

Sign here

Questionnaire Submitted

Thank you. Your responses have been saved and will be available for your therapist at your appointment. Please bring your photo ID with you.

Patient Questionnaire

Clinician Assessment

Admin / Config

New Appointment

Upcoming Appointments

Client Profiles & Module Settings

Client Details

Assessment Modules

Audiometry

Spirometry

Drug & Alcohol Screen (DAS)

Vision & Colour Vision

Urinalysis

3-Minute Step Test

Manual Handling — Lifting

Manual Handling — Carrying & Pulling

Climbing / Stepping

Full MSK Examination

AUDIT Questionnaire

K10 Psychological Questionnaire

Epworth Sleep Scale

Work History

Identity Verification — Complete Before Assessment

No patient questionnaire loaded

⚑ Low back injury — previous history

⚑ Tinnitus — reported

Measurements

Hearing Thresholds (dB HL)

Spirometry Results

Urinalysis Results

Visual Acuity

Visual Acuity — Findings

Colour Vision — Ishihara (14 plates)

Joint ROM Assessment

ROM Additional Comments

Postural Findings

Grip Strength Results

2-Minute Postural Tests

Step Test Results

Step-Up — 500mm

Ladder Climbing — Endurance Protocol

Summary of Key Findings

In the opinion of the assessor, the applicant has:

Assessor Details