Pre Consult Assessment Medical Certifate

For your safety, we need to ask you some questions.At any stage if you feel very unwell or your symptoms get worse, you must seek immediate medical attention.

I confirm I am in Australia and my Qoctor profile (if previously registered) is up to date.*

Yes
No

I confirm that I am not seriously unwell, I just need a medical certificate*

Yes
No

I confirm that I do NOT have any of the following symptoms currently:*

○ Chest pain
○ Shortness of breath
○ Unable to swallow fluids or saliva
○ Weakness or numbness down one side
○ Slurred speech

Yes
No

Have you ever had any of the following conditions? ( leave blank if none apply)

I need a certificate for one of the following conditions (please select one)*

Have your symptoms lasted for 7 days or more?*

Yes
No

Do you have severe tummy pain?*

Yes
No

Are you dehydrated? (Dizzy, unable to drink sips of fluid, passing little or no urine)*

Yes
No

Is there blood in your vomit or poo, or is your poo black and tarry?*

Yes
No

Do you have any previous stomach or bowel conditions?*

Yes
No

Have you had back pain for more than 7 days?*

Yes
No

Do you have any of the following:*

○ Back pain radiating into one or both legs
○ Pins and needles/numbness or around your anus or behind your genitalia
○ Any weakness in your legs
○ Loss of bladder or bowel control
○ Any urinary symptoms (for example, pain when passing urine or passing urine more frequently)
○ Any fever or ‘flu-like’ symptoms
○ Unexplained weight loss

Yes
No

Have your headaches been previously confirmed as migraine by your doctor?*

Yes
No

Do you have a fever, flu like symptoms or confusion with your current headache?*

Yes
No

Is your current headache far more severe than your previous migraines?*

Yes
No

Have you had a head injury in the last 2 weeks?*

Yes
No

Do you have uncontrolled hypertension (high blood pressure)?*

Yes
No

Is there any chance you could be pregnant?*

Yes
No

Do you have a fever or flu like symptoms?*

Yes
No

Do you have any foul smelling/abnormal vaginal discharge?*

Yes
No

Is this period pain much more severe than previous episodes?*

Yes
No

Do you have any of the following:*

○ Headache accompanied by neck stiffness
○ Discomfort when looking at bright lights
○ Rash which doesn't fade when you press on it
○ Difficulty in breathing
○ Chest pain
○ Coughing up blood/blood stained phlegm
○ Unable to swallow solids and fluids

Yes
No

What dates do you need the certificate for?

From*

To*

Please select a time slot for your video consultation from the drop-down menu below*

Special Notes

I confirm I do not think I need to see a GP in person.*

Yes

If my symptoms continue or get worse I will see my GP in person*

Yes

Does your current health issue (reason for booking this appointment) relate to a legal matter, court appearance or a Workcover/insurance claim?*

Yes
No

I have read and accept the terms and conditions.*

Yes

In certain situations, a longer GP consultation will allow us to meet your needs more effectively. This includes:*

○ If your university/employer requires an additional special form to be completed for your sick leave
○ If your sick leave started more than a week ago
○ If you have already had 2 or more medical certificates in the past 4 weeks
○ If you have a long term, recurring or complex medical condition
○ If you need to discuss other health issues

Do any of the above circumstances apply to you?

Yes
No

What's next?
• Click “continue” below to go to the next page, where you’ll complete the final steps of your booking.
• You’ll be asked to login if you haven’t already done so.
• When you have completed checkout, you’ll get a confirmation email.
• Later, you’ll get another SMS and email, 15minutes before your appointment slot, with a video link to your appointment.

Medial Cetificate

Total

$0.00

Pre Consult Assessment Medical Certifate

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