Medical Assessment for Transport Disability Instructions
This form contains 107 fields organized into 30 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Ability Level for Educational Skills | ||
| Full ability | Checkbox |
Check this box if the patient has full ability in educational skills, such as handling money or buying tickets. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Slightly limited | Checkbox |
Check this box if the patient has slightly limited ability in educational skills, such as handling money or buying tickets. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderately limited | Checkbox |
Check this box if the patient has moderately limited ability in educational skills, such as handling money or buying tickets. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severely limited | Checkbox |
Check this box if the patient has severely limited ability in educational skills, such as handling money or buying tickets. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No ability | Checkbox |
Check this box if the patient has no ability in educational skills, such as handling money or buying tickets. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Ability Level for Personal Survival Skills | ||
| Full ability (Personal survival skills) | Checkbox |
Check this box if the patient has full ability regarding personal survival skills, meaning they are not a danger to themselves. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Slightly limited ability (Personal survival skills) | Checkbox |
Check this box if the patient has slightly limited ability regarding personal survival skills. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderately limited ability (Personal survival skills) | Checkbox |
Check this box if the patient has moderately limited ability regarding personal survival skills. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severely limited ability (Personal survival skills) | Checkbox |
Check this box if the patient has severely limited ability regarding personal survival skills. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No ability (Personal survival skills) | Checkbox |
Check this box if the patient has no ability regarding personal survival skills. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Ability Level for Recognition Skills | ||
| Q64_1 | CheckBox |
Depends on:
Yes
|
| Slightly limited | Checkbox |
Check this box if the patient has slightly limited ability to recognise landmarks or areas. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderately limited | Checkbox |
Check this box if the patient has moderately limited ability to recognise landmarks or areas. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severely limited | Checkbox |
Check this box if the patient has severely limited ability to recognise landmarks or areas. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No ability | Checkbox |
Check this box if the patient has no ability to recognise landmarks or areas. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Ability Level for Social Skills | ||
| Social skills - Full ability | Checkbox |
Check this box if the patient has full ability in social skills, such as relating to bus drivers or the public. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Social skills - Slightly limited | Checkbox |
Check this box if the patient has slightly limited ability in social skills, such as relating to bus drivers or the public. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Social skills - Moderately limited | Checkbox |
Check this box if the patient has moderately limited ability in social skills, such as relating to bus drivers or the public. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Social skills - Severely limited | Checkbox |
Check this box if the patient has severely limited ability in social skills, such as relating to bus drivers or the public. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Social skills - No ability | Checkbox |
Check this box if the patient has no ability in social skills, such as relating to bus drivers or the public. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Additional Information on Limitations | ||
| Q7_No | CheckBox | |
| Q7 | CheckBox | |
| Additional Public Transport Limitations | Text |
Provide any brief additional information about how disabilities, illnesses, or injuries limit the patient's ability to use public transport.
|
| Detailed Public Transport Limitations | Text |
Enter comprehensive details about how the patient's disabilities, illnesses, or injuries limit their ability to use public transport. Fill only if 'Q7' is 'Yes'.
Depends on:
Q7
|
| Address | ||
| Address Line 1 | Text |
Please provide the first line of the customer's address.
|
| Address Line 2 | Text |
Please provide the second line of the customer's address, such as suburb and state.
|
| Postcode | Text |
Please provide the postcode for the customer's address.
|
| Address Line 1 | Text |
Please provide the first line of the address.
|
| Address Line 2 | Text |
Please provide the second line of the address, if applicable.
|
| Postcode | Text |
Please provide the postcode.
|
| Centrelink Reference Number | ||
| Centrelink Reference Number Segment 1 | Text |
Enter the first part of your Centrelink Reference Number, if known.
|
| Centrelink Reference Number Segment 2 | Text |
Enter the second part of your Centrelink Reference Number, if known.
|
| Centrelink Reference Number Segment 3 | Text |
Enter the third part of your Centrelink Reference Number, if known.
|
| Centrelink Reference Number Segment 4 | Text |
Enter the fourth part of your Centrelink Reference Number, if known.
|
| Claim Number | ||
| Claim Number | Text |
Please provide the claim number if it is known.
|
| Date of Birth | ||
| Date of Birth | Date |
Please provide the customer's date of birth.
|
| Difficulty Level for Crossing Streets and Negotiating Kerbs | ||
| No difficulty | Checkbox |
Check this box if the patient experiences no difficulty when crossing streets and negotiating kerbs. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Minor difficulty | Checkbox |
Check this box if the patient experiences minor difficulty when crossing streets and negotiating kerbs. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate difficulty | Checkbox |
Check this box if the patient experiences moderate difficulty when crossing streets and negotiating kerbs. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Serious difficulty | Checkbox |
Check this box if the patient experiences serious difficulty when crossing streets and negotiating kerbs. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Cannot do | Checkbox |
Check this box if the patient cannot cross streets and negotiate kerbs at all. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Difficulty Level for Negotiating a Large Flight of Steps | ||
| No difficulty | Checkbox |
Check this box if the patient experiences no difficulty when negotiating a large flight of steps. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Minor difficulty | Checkbox |
Check this box if the patient experiences minor difficulty when negotiating a large flight of steps. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate difficulty | Checkbox |
Check this box if the patient experiences moderate difficulty when negotiating a large flight of steps. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Serious difficulty | Checkbox |
Check this box if the patient experiences serious difficulty when negotiating a large flight of steps. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Cannot do | Checkbox |
Check this box if the patient is unable to negotiate a large flight of steps. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Difficulty Level for Negotiating Steps in or out of Public Transport | ||
| No difficulty | Checkbox |
Check this box if the patient experiences no difficulty when negotiating steps in or out of public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Minor difficulty | Checkbox |
Check this box if the patient experiences minor difficulty when negotiating steps in or out of public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate difficulty | Checkbox |
Check this box if the patient experiences moderate difficulty when negotiating steps in or out of public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Serious difficulty | Checkbox |
Check this box if the patient experiences serious difficulty when negotiating steps in or out of public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Cannot do | Checkbox |
Check this box if the patient is unable to negotiate steps in or out of public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Difficulty Level for Sitting in Public Transport | ||
| Q43_1 | CheckBox |
Depends on:
Yes
|
| Q43_2 | CheckBox |
Depends on:
Yes
|
| Q43_3 | CheckBox |
Depends on:
Yes
|
| Q43_4 | CheckBox |
Depends on:
Yes
|
| Q43_5 | CheckBox |
Depends on:
Yes
|
| Difficulty Level for Standing on Public Transport | ||
| No difficulty | Checkbox |
Check this box if the patient experiences no difficulty standing on public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Minor difficulty | Checkbox |
Check this box if the patient experiences minor difficulty standing on public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate difficulty | Checkbox |
Check this box if the patient experiences moderate difficulty standing on public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Serious difficulty | Checkbox |
Check this box if the patient experiences serious difficulty standing on public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Cannot do | Checkbox |
Check this box if the patient is unable to stand on public transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Difficulty Level for Walking 400 Metres | ||
| No difficulty | Checkbox |
Check this box if the patient experiences no difficulty when walking 400 metres. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Minor difficulty | Checkbox |
Check this box if the patient experiences minor difficulty when walking 400 metres. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate difficulty | Checkbox |
Check this box if the patient experiences moderate difficulty when walking 400 metres. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Serious difficulty | Checkbox |
Check this box if the patient experiences serious difficulty when walking 400 metres. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Cannot do | Checkbox |
Check this box if the patient cannot walk 400 metres at all. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Disability Status Inquiry | ||
| No | Checkbox |
Check this box if the patient does not have any physical, psychiatric, or intellectual disabilities.
|
| DummyCalcQ2 | Text | |
| Yes | Checkbox |
Check this box if the patient has any physical, psychiatric, or intellectual disabilities.
|
| Duration of Difficulty | ||
| Less than 12 months | Checkbox |
Check this box if the patient's level of difficulty or discomfort in using public transport is likely to last less than 12 months. Fill only if 'Temporary' is 'Yes'.
Depends on:
Temporary
|
| 12 months or longer | Checkbox |
Check this box if the patient's level of difficulty or discomfort in using public transport is likely to last 12 months or longer. Fill only if 'Temporary' is 'Yes'.
Depends on:
Temporary
|
| Full Name | ||
| Full Name | Text |
Enter the full name of the customer.
|
| General | ||
| Instructions | Button | |
| Q2GoToQ11 | Button | |
| Q3GoToQ5 | Button | |
| Q5GoToQ7 | Button | |
| Q8GoToQ10 | Button | |
| DoctorAddress1 | Text | |
| DoctorAddress2 | Text | |
| Button | ||
| Clear | Button | |
| Name | ||
| Doctor's Name | Text |
Provide the full name of the doctor completing this report.
|
| Patient History | ||
| Enter the date in DD/MM/YYYY format | Text | |
| Enter the date in DD/MM/YYYY format | Text | |
| Permanence of Difficulty | ||
| Permanent | Checkbox |
Check this box if the patient's difficulty or discomfort in using public transport is likely to be permanent.
|
| DummyCalcQ8 | Text | |
| Temporary | Checkbox |
Check this box if the patient's difficulty or discomfort in using public transport is likely to be temporary.
|
| Phone number | ||
| Phone Number Prefix | Text |
Please enter the prefix or area code of the phone number.
|
| Phone Number Suffix | Text |
Please enter the main part of the phone number.
|
| Phone Number | ||
| Phone Number First Part | Text |
Provide the first part of the customer's phone number, such as the area code.
|
| Phone Number Second Part | Text |
Provide the second part of the customer's phone number.
|
| Physical Disabilities Inquiry | ||
| Q3_No | CheckBox | |
| DummyCalcQ3 | Text | |
| Yes | Checkbox |
Check this box if the patient has physical disabilities and details are provided.
|
| Physical Disability Details | Text |
Provide a comprehensive description of the patient's physical disabilities, including any relevant information. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Professional qualifications | ||
| Professional qualifications | Text |
Please provide your professional qualifications.
|
| Provider number | ||
| Provider Number | Text |
Please enter your provider number.
|
| Psychiatric or Intellectual Disabilities Inquiry | ||
| No | Checkbox |
Check this box if the patient does not have any psychiatric or intellectual disabilities.
|
| DummyCalcQ5 | Text | |
| Yes | Checkbox |
Check this box if the patient has psychiatric or intellectual disabilities.
|
| Psychiatric or Intellectual Disabilities Details | Text |
Provide details regarding the patient's psychiatric or intellectual disabilities. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Release of medical information | ||
| No | Checkbox |
Check this box if there is no information in the report that might be prejudicial to the patient's physical or mental health if released.
|
| Yes | Checkbox |
Check this box if there is information in the report that might be prejudicial to the patient's physical or mental health if released, and you need to identify it and explain why it should not be released directly to the patient.
|
| Prejudicial Information Identification | Text |
Identify the information in this report which, if released to the patient, might be prejudicial to their physical or mental health. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reason for Non-Release | Text |
State the reasons why the identified information should not be released directly to the patient, including any special circumstances. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Signature and Date | ||
| Signature | Text |
Please provide the signature for this report.
|
| Date | Date |
Please enter the date the report was signed.
|