SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017
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1 SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017 PLEASE NOTE THIS IS FOR GUIDANCE ONLY AND IS SUBJECT TO CHANGE PART A Applicant Personal Information PART B Applicant General Health Information PART C Applicant Medical History PART D Applicant Vaccination and Immunisation History PART E Applicant Declaration to be signed and dated Please complete all the relevant parts with as much information as possible. Your completed questionnaire with health details is required to enable the Occupational Health screening provider to complete an assessment of your health and well being in relation to your proposed course, your ability to perform this role and whether any adjustments or provision of equipment or aids will be required in order for you to perform this role. Please refer to the information at: whilst completing this form. PART A Applicant Personal Information Surname: First Name(s): Title: Mr / Mrs / Miss / Ms / Male / Female D.O.B. National Insurance No. Home Address: Tel (Home): Mobile: GP Details: Dr Address: Postcode: Tel No: Course Applied For: Location/Department: Course Supervisor: (if known) Start Date:
2 PART B Applicant General Health Information Any issues or queries requiring clarification will be discussed at your Occupational Health appointment. Please answer the following questions as accurately as possible. Please delete as appropriate Are you currently exposed to latex? If yes give details, e.g. wear gloves daily. Have you been diagnosed with a latex allergy? If yes please give details: Has any employment ever been terminated on health grounds? If Yes please give details: Do you have any disability you wish to disclose in order that assistance or help with modifications to your workplace can be provided? If Yes please give details:
3 PART C Applicant Medical History Do you have or have you had any of the following? Please place a tick in the yes or no box, and if you answer yes then please give further details. CONDITION YES NO DETAILS (dates, treatments, medications) Back problems Prolonged pain or injury to neck or shoulders Problems with your hands, arms, legs or feet Rheumatism, arthritis or other joint problems Migraine or frequent headaches Fits, epilepsy, fainting or giddiness Psychiatric illness or nervous conditions. Depression or anxiety Disease of the nervous system, e.g. multiple sclerosis Heart Disease, angina, raised blood pressure Asthma, bronchitis, pneumonia, TB or chest disease Breathlessness, palpitations, swelling of the ankles Frequent bouts of Cystitis, bladder or kidney disease Frequent indigestion, stomach or bowel disorders
4 CONDITION YES NO DETAILS (dates, treatments, medications) Hernia, rupture or varicose veins Diabetes, thyroid or gland disease Jaundice or hepatitis Recurrent tonsillitis, sinusitis or hay fever Discharging ears, perforated eardrum, or hearing impairment Frequent/recurrent eye infections Dermatitis, eczema, or other skin complaints Have you ever had chicken pox or shingles? Have you ever had measles or mumps? Have you ever been treated for any drug or alcohol addiction, or eating disorders? Are you allergic to any food, drug, chemicals or any other materials? Have you ever attended hospital as an in/out patient? Please specify? Have you had any defect of sight, do you wear spectacles or contacts? Have you had more than 2 weeks sickness absence from work / school within the last 2 years? PART D Applicant Vaccination and Immunisation History
5 It is a pre-requisite that you obtain from your GP a print out of all your inoculations from birth to date. If you have had any inoculations at school or elsewhere, you will also need to obtain these. It is very important for those students who are to perform exposure prone procedures to make. aware if they have tested positive or have never been tested for any transmissible blood-borne virus infection, e.g. Hepatitis B or C, or HIV. Have you ever tested positive for any blood-borne virus infection? (please tick relevant box) Yes No Never Tested Date(s) Management/Treatment Have you had Yes No Year TB Immunity Test (Mantoux) BCG Inoculation A course of Hepatitis B Inoculations 5 Year Booster Due: Hepatitis B Antibody Test.miu/litre (lab report enclose copy if possible) Measles/Mumps/Rubella Inoculations x2 Rubella Antibody Test Immune / Non-immune (lab report enclose copy if possible) Diptheria/Tetanus/Polio Inoculations Meningitis C Inoculation Any other inoculations, please state
6 PART E Applicant Declaration to be signed and dated Please read the declaration below and sign and date that you have understood it. I declare that the information given in this document is true and complete to the best of my knowledge, and I understand that failure to disclose information may affect my acceptance onto the course. 1. I consent to a medical examination if necessary and that relevant details and results of any tests may be sent to my General Practitioner. 2. I agree to undergo blood tests and accept inoculations necessary to undertake the duties of the course. 3. I have obtained a printout of my vaccination history and attached it to this form. Signature:.. Date:
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