Djinda Health Medical Assessment Booking Form
Date and time of the request
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Day
-
Month
Year
Date
Hour Minutes
Candidates Details
Candidate's Full name
*
First Name
Last Name
Candidate's Date of Birth
*
-
Day
-
Month
Year
Date
Candidate's Phone Number
*
Please enter a valid phone number.
Candidate's Email Address
*
example@example.com
Candidate's Proposed Role
*
Job Location / Site
Preferred Date for Medical
*
-
Day
-
Month
Year
Date
Preferred Appointment Time
*
Morning
Afternoon
Anytime
Select Medical Assessment Components
Medical Overview (Height; Weight; BMI; Blood Pressure; Urinalysis; Vision; Ears; Nose; Throat; Mouth Examination; Respiratory; Cardiovascular; Gastrointestinal; Skin; Nervous System; Range of Movement
Musculoskeletal Assessment
Functional (Step Test)
Audiometry
Spirometry
Laboratory Drug Screen
Instant Drug Screen
Mask Fit (Please state what type of Mask is required)
Ear Fit (Please state which type of Ear Fit is required)
ECG (Resting)
Instant Bloods (BSL, HbA1c, Lipids)
Pathology Bloods
Cardiac Risk Score
Heat Stress Assessment
Nickel Allergy Assessment
Specialised Medicals
Commercial Driver
Dangerous Goods
Rail CAT 1
Rail CAT 2
Rail CAT 3
OGUK Medical
Boxing / MMA
Horse Racing (Thoroughbred and Harness)
Go Cart / Speedway
Pest Technician Medical
Occupational Physician Review
If a Mask Fit is required, please select.
Disposable
Reusable
Disposable and Reuseable (Each test is billed separately)
If an Ear Fit is required, please select (Note 3M products have adapters for testing)
Disposable
Reusable Ear Muffs (These must be brought with the client for the EARfit test)
Disposable and Reuseable (Each test is billed separately)
Additional Notes / Questions
Please use the below option to attach any Medical letters from GP/ Specialists, regarding existing medical conditions and a list of medications. Letters must be dated within the last 4wks.
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