Date for Medical Certificate

Reason for Certificate
WorkSchool / University

Do you feel temporarily unwell but believe a full doctor consultation is not necessary?
YesNo

Please select your current symptoms
Mild viral symptoms (such as cold, flu, or COVID)Menstrual discomfortMild lower back strainHeadache or migraine (same as previous episodes)Minor injuryMild sore throat (able to eat and drink)Diarrhoea (without blood or mucus)Toothache (awaiting dental review)General fatigue or stressOther mild, short-term symptoms

Do you currently have any of the following symptoms?
Chest pain, palpitations, or shortness of breathWeakness or changes in sensation in any part of the bodyBlurred vision or slurred speechNew or severe headache with reduced alertness (not typical migraine or tension headache)Neck stiffnessRash that does not fade when pressedExcessive vomiting or inability to tolerate food or fluidsHigh fever over 39°C with chills or rigors

Thoughts of self-harm or suicide
YesNo

Do you have any significant current or past medical conditions?
YesNo

If you don’t get better, will you go see a GP in person within the next 24-48 hours?
YesNo

Are you in Australia?
YesNo

Have you read and accept the terms and conditions?
YesNo

Your Details

Full Name (First and Last)

Gender
MaleFemaleOther

Mobile Number

Email Address

Date of Birth

Residential Address

Suburb

State

Postcode