Form Q1 - Health Status Questionnaire

Please answer the questions by ticking the correct box. If you are not sure, leave the question blank and ask your health advisor what it means. Your health advisor may ask you additional questions during the examination.

Full Name *

Please enter your full name.

IC No. or Passport No.*

Please enter your Company or Service No. as per your company's.

Company ID or Service No.*

Please enter your Company ID or Service No. if applicable.

Job Title

Please enter your job title if applicable.

Date of Birth*

DayMonthYear

Age*

Please enter your age.

Please answer the following:*

Rows	Yes	No
1.1 Are you currently being treated by a doctor for any illness or Injury?

Rows	Yes	No
1.2 Are you receiving any medical treatment or taking any medication (either prescribed or otherwise)?

1.3 Please list illness and medical treatment below.

Have you ever had, or been told by a doctor that you had any of the following:*

Rows	Yes	No
2.1 High blood pressure
2.2 Heart disease
2.3 Chest pain, angina
2.4 Any conditions requiring heart surgery
2.5 Palpitations/irregular heartbeat
2.6 Abnormal shortness of breath
2.7 Head injury, spinal injury
2.8 Seizures, fits, convulsions, epilepsy
2.9 Blackouts/fainting
2.10 Stroke
2.11 Dizziness, vertigo, problems with balance
2.12 Double vision, difficulty seeing
2.13 Colour blindness
2.14 Kidney disease
2.15 Diabetes
2.16 Neck, back or limb disorders
2.17 Hearing loss or deafness or had an ear operation or use a hearing aid
2.18 Do you have difficulty hearing people on telephone (Including use of hearing aid if worn)?
2.19 Have you ever had, or been told by doctor that you had a psychiatric illness or nervous disorders?
2.20 Have you ever had any serious injury, illness, operation, or been in hospital for any reason?
2.21 Have you ever had, or been told by a doctor that you had a sleep disorder, sleep apnoea, or narcolepsy?
2.22 Has anyone noticed that your breathing stops or is disrupted by episodes of choking during your sleep?

Rows	Yes	No
3.1 Have you ever been diagnosed with cancer?

3.2 What type of cancer?

Rows	Yes	No
4.1 Do you smoke?

Rows	Cigarette	eCigarette	Vape
4.2 What type?

4.3 How much do you smoke each day?

Rows	Yes	No
5.1 Do you drink alcohol?

Rows	Time Frame
5.2 When was the last time you had more than 4 units alcoholic drinks (female) or 5 drinks (male) in 1 day in the past 3 months?

Rows	Time Frame
5.3 Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Rows	Yes	No
5.4 Have you ever been treated for Alcohol abuse?

Rows	Yes	No
6.1 Do you take recreational drugs?

Rows	Yes	No
6.2 Have you ever been treated for substance abuse?

Rows	Yes	No
7.1 Do you have a driver's license?

Rows	Yes	No
7.2 Have you been in a vehicle crash since your last license Examination?

7.3 Please give details

I, certify that the above information which i have supplied are true and correct to the best of my knowledge.*

Insert your e-Signature below.*

Health Status Questionnaire

Employee Details

Recreational Substance Use

Motor Vehicle User History