Pre-Employment Health Questionnaire

Please PRINT Personal Details to ensure staff can enter details correctly onto The Keogh Practice record system

Date of Completion required

Company

Phone

Shift work

Yes

Position Applied for

Date of Birth (PRINT)

First and Last Name

Home Address

Family Doctor

Covid Screening

Do you have any symptoms or belive you have Covid 19 or influenza currently?

Yes

Medical Consent

I confirm that I have been told about this assessment, what the reasons are, and that records will be kept, and I agree to take part in the examination. I confirm I understand the purpose of the assessment is to provide my employer with advice regarding my fitness for work and any advice will be expressed in terms of fitness to carry out my duties now and in the future.

Occupational History

Please give brief details on job titles, employers, dates of employment and hazard exposures. *Please note that hazards can include: Manual handling, Chemicals, Noise and Extreme temperatures

Social History

Smoking?

Yes

Vaping?

Yes

Do you drink alcohol?

Yes

Do you exercise?

Yes

If yes, how many per day? Have you ever smoked? When did you stop?

Did you ever vape? When did you start/stop?

How many units per week? (2 units of alcohol = glass of wine/pint of beer)

Type of exercise and frequencey?

Medical History

Current health

If you say yes to any question, please give more detail at the end of each section in the box provided

01.Are you currently under medical care?

Yes

02.Have you had any operations?

Yes

03.Have you been in hospital otherwise?

Yes

04.Are you allergic to anything? (This can include medication but also chemicals/latex or hay fever type allergy)

Yes

05.Are you taking any Medications?

Yes

06.Are you receiving any treatment or waiting for any treatment or investigations at the moment?

Yes

If you answered 'Yes' to any of the above, please add details and dates.

Do you suffer from or have you ever had?

Current Health

01.Have you lost time from work or education due to sickness in the last 2 years?

Yes

02.A fear of confined spaces (claustrophobia)

Yes

03.A fear of heights or open spaces (agoraphobia)

Yes

04.Fainting/ Dizziness/ Fits /Blackouts/ Epilepsy

Yes

05.Recurrent headaches or Migraine

Yes

06.Mental illness or nervous trouble (including anxiety or depression or any stress related illness)

Yes

07.Eye disorder or disturbance of vision

Yes

10.Tuberculosis

Yes

13.Any heart disease or disorder? (Including pacemaker)

Yes

16.Any skin problem such as Dermatitis, Psoriasis, eczema, or skin allergy (including chemical or latex allergy)

Yes

19.Lower limb injury or trouble

Yes

22.Do you believe you have any health issues that may need work accommodation?

Yes

08.Any chest complaint(s)?

Yes

11.High Blood Pressure

Yes

14.Diabetes

Yes

17.Back or neck trouble e.g., muscular problems, whiplash, disc prolapse

Yes

20.Arthritis, joint problems, gout?

Yes

23.Any other significant medical condition?

Yes

09.Asthma

Yes

12.Any Gastrointestinal problems (can include IBS, Crohn’s, colitis etc.)

Yes

15.Drug or alcohol misuse

Yes

18.Upper limb injury or trouble (work related or otherwise)?

Yes

21.Have you ever had pain or discomfort when bending or lifting?

Yes

24.Ever played in a band or shoot guns? If so, what hearing protection was/is used?

Yes

25.Ear or hearing trouble, ear infections, or deafness or family deafness (in younger years)

Yes

26.Did you ever work in a loud environment where you had to raise your voice to be heard? If yes, please specify employer and duration of employment

Yes

If you answered 'Yes' to any of the above, please add details and dates.

I undertake to notify my employer/ regulatory bodies (if applicable) immediately of any subsequent change to my state of health or other concerns that may affect my fitness to work.

I declare that the information provided is truthful and that I have disclosed all relevant information regarding my health and fitness to work. I acknowledge that failure to disclose information, or submission by me of information that is subsequently found to be false may render my employment Null and Void

I give permission for my pre-employment assessment record to be shared with onsite Occupational Health department for the purpose of ongoing on-site occupational health support and monitoring in line with HSA compliance and will be shared by secure file share.

I acknowledge I must be 16 hours noise free before doing the hearing test to get an accurate reading. This means avoiding loud noise e.g. DIY or concerts without hearing protection 16 hours before doing the medical. If you are unsure if you have been exposed to loud noise, please make the nurse aware on the day of the medical.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

I have voluntarily completed this questionnaire and I certify that the answers arc accurate. I understand that it is necessary that I declare all relevant Inedical details 10 protect my health and that of other employees. hereby authorise the exalnining doctor to furnish a report and to discuss with the Company thc results of the examination and other relevant Incdical issues in connection with my application for employinent.

Signed: _____________________________________________ Date: _____ /_____ / ________

This file is confidential and will bc retained in the Occupational Health Department

Pre-Employment Health Questionnaire

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