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.

  • Please review the following job roles and tick the one which best describes the type of work you will be doing.*
  • Do you consider yourself to have a disability?*
  • Have you ever consulted or been recommended to consult a medical or surgical specialist?*
  • Have you ever been an in-patient in a hospital or nursing home?*
  • Have you ever suffered with an occupational health condition or injury arising out of your work? (e.g. Noise Induced Hearing Loss, Vibration White Finger, etc.)*
  • Have you ever had a severe illness or injury?*
  • Have you ever had a nervous breakdown, anxiety state, depression, or other mental illness?*
  • Have you ever had a history of heart disease, high blood pressure or rheumatic fever?*
  • Have you ever had any allergies or sensitivity disorders, e.g., hay fever, nettle rash etc.?*
  • Have you ever coughed up blood, had a prolonged or persistent cough, bronchitis, pneumonia, tuberculosis or other chest problem?*
  • Have you ever suffered from any recurrent indigestion, stomach trouble, ulcer, jaundice, gall bladder or bowel disorder, rupture, or hernia*
  • Have you ever had kidney, bladder, prostate problems, or diabetes?*
  • Have you ever had attacks of giddiness, unconsciousness, fits, blackouts, paralysis or severe headaches?*
  • Have you ever had rheumatism, lumbago, sciatica, prolonged back or neck pain; any other joint problems?*
  • Have you ever had dermatitis or any other skin problems?*
  • Do you have any defects of sight, hearing or other senses?*
  • Do you suffer from eyestrain or wear glasses?*
  • Do you wear a hearing aid?*
  • Have you ever had any medical treatment during the last 3 years or visited a doctor during this time?*
  • Do you have any reason to expect to ask for leave of absence on medical grounds in the future?*
  • Do you intend to work nights on a regular basis?*
  • 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?*
  • 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.*
  • Do you have any further relevant information that you wish to add?*
  • Are you receiving regular treatment/medicine from your doctor?*

  • 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.

  • 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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