Medical History

Name

First Last

Email*

Email of the migration agent assisting you with your application*

Matter ID

Usually first four letters of your surname followed by 4 digits, for example: SMIT0003

Have you ever been diagnosed with Tuberculosis (TB)? Have you ever had to take treatment for Tuberculosis (TB)?*

Yes
No

Have you ever been in close contact at work or at home with a person known to have Tuberculosis (TB)?*

Yes
No

Have you ever been admitted to hospital and/or received medical treatment for an extended period for any reason (including for a major operation or treatment of a psychiatric illness)?*

Yes
No

Do you suffer, or have you ever suffered, from mental health problems?*

Yes
No

Have you ever been told you are HIV positive?*

Yes
No

Have you ever had a positive Hepatitis B or Hepatitis C blood test?*

Yes
No

Do you have or have you had cancer in the last 5 years?*

Yes
No

Do you have high blood sugar / diabetes?*

Yes
No

Do you have heart problems, including high blood pressure or a heart condition that you were born with?*

Yes
No

Do you have a blood condition?*

Yes
No

Do you have bladder or kidney problems?*

Yes
No

Do you have a physical or intellectual disability that makes it difficult for you to function independently (for example, to move around or learn) or be able to work full-time?*

Yes
No

Are you, or have you ever been, addicted to drugs or alcohol?*

Yes
No

Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the counter medication and natural supplements)? If yes, please list these.*

Yes
No

Are you pregnant? (if applicable)*

Yes
No

If you are pregnant and intend to give birth in Australia, additional testing for Hepatitis B may be added to your Health Case at the time of examination.

Anything else you would like to tell us?

Client declaration

I declare that the information that I have provided in terms of my medical history on the above form is true and correct.

Signature*

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Medical History

Medical History

Core Skills Occupations List (CSOL)

Mobility Arrangement for Talented Early-professionals Scheme (MATES)

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Immigration Lawyer* Melbourne

Lawyers*

TR to PR

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Melbourne Office