Occupational health form

Occupational health form

STRICTLY CONFIDENTIAL ONCE COMPLETED
In order to assess what risks or precautions may need to be taken into account, we need an appreciation of the demands that your job will create. These will differ from office-based positions in which little physical activity is required, to working on a construction site, carrying out heavy manual work.
Name*

First NameLast Name
NI Number
Please review the following job roles and tick the one which best describes the type of work you will be doing.*

Office BasedOffice based with some manual activity or occasional visits to construction sites or physically demanding environmentsSite Office BasedSite Office based with occasional visitsmon to construction sites and/or physically demanding environmentsSite Based
Do you consider yourself to have a disability?*

YesNo
Please write additional explanatory information
Have you ever consulted or been recommended to consult a medical or surgical specialist?*

YesNo
Please write additional explanatory information
Have you ever been an in-patient in a hospital or nursing home?*

YesNo
Please write additional explanatory information
Have you ever had any industrial disease or injury arising out of your work? (e.g. Noise Induced Hearing Loss, Vibration White Finger, etc.)*

YesNo
Please write additional explanatory information
Have you ever had a severe illness or injury?*

YesNo
Please write additional explanatory information
Have you ever had a nervous breakdown, anxiety state, depression, or other mental illness?*

YesNo
Please write additional explanatory information
Have you ever had a history of heart disease, high blood pressure or rheumatic fever?*

YesNo
Please write additional explanatory information
Have you ever had any allergies or sensitivity disorders, e.g., hay fever, nettle rash etc.?*

YesNo
Please write additional explanatory information
Have you ever coughed up blood, had a prolonged or persistent cough, bronchitis, pneumonia, tuberculosis or other chest problem?*

YesNo
Please write additional explanatory information
Have you ever suffered from any recurrent indigestion, stomach trouble, ulcer, jaundice, gall bladder or bowel disorder, rupture, or hernia*

YesNo
Please write additional explanatory information
Have you ever had kidney, bladder, prostate problems, or diabetes?*

YesNo
Please write additional explanatory information
Have you ever had attacks of giddiness, unconsciousness, fits, blackouts, paralysis or severe headaches?*

YesNo
Please write additional explanatory information
Have you ever had rheumatism, lumbago, sciatica, prolonged back or neck pain; any other joint problems?*

YesNo
Please write additional explanatory information
Have you ever had dermatitis or any other skin problems?*

YesNo
Please write additional explanatory information
Do you have any defects of sight, hearing or other senses?*

YesNo
Please write additional explanatory information
Do you suffer from eyestrain or wear glasses?*

YesNo
Please write additional explanatory information
Do you wear a hearing aid?*

YesNo
Please write additional explanatory information
Have you ever had any medical treatment during the last 3 years or visited a doctor during this time?*

YesNo
Please write additional explanatory information
Do you have any reason to expect to ask for leave of absence on medical grounds in the future?*

YesNo
Please write additional explanatory information
Do you intend to work nights on a regular basis?*

YesNo
Please write additional explanatory information
Has any illness or medical condition prevented you from attending work or fulfilling your normal duties or activities for more than one week during the past year?*

YesNo
Please write additional explanatory information
Do you have any physical or mental impairment which has a substantial and long-term effect on your ability to carry out day to day activities? If yes, please specify any special adjustments required in relation to work.*

YesNo
Please write additional explanatory information
Do you have any further relevant information that you wish to add?*

YesNo
Please write additional explanatory information
Are you receiving regular treatment/medicine from your doctor?*

YesNo
Please describe your symptoms, prescribed medication, and treatment.
I confirm that the answers that I have given are, to the best of my knowledge and belief, true. I realise that the Company will rely on this information. Should the company require further medical information. I hereby consent to the Company’s Medical Adviser contacting my General Practitioner (in accordance with the provisions of the “Access to Medical Reports Act 1988”). Alternatively, I would be prepared to undergo a examination by the Company’s Medical Adviser should the Company so desired.
Signature

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Note: All personal information submitted will be processed fairly and lawfully. Information will be held confidentially in line with current data protection laws and will only be processed to ensure that employees are fit to perform their duties. Personal information will not be shared for any purpose other than with the Medical Adviser agreed above.
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