Proper Cornish - Health Form

PERSONAL HEALTH QUESTIONNAIRE

QA-076
Date

MonthDayYear
Date
Title*

MrMrsMissMs
Name
Department
Do you wear glasses/contact lenses?*

YesNo
Do you have good hearing in both ears?*

YesNo
Do you have nose or throat problems?*

YesNo
Do suffer with discharge from eyes, ears or gums?*

YesNo
Do have any chest problems?*

YesNo
Do suffer from heart disease or angina?*

YesNo
Do suffer from either high or low blood pressure?*

YesNo
Do suffer from fainting attacks or giddiness?*

YesNo
Do suffer from blackouts, epilepsy or fits?*

YesNo
Do suffer from headaches or migraines?*

YesNo
Are you diabetic?*

YesNo
Are you asthmatic?*

YesNo
Do you suffer from stomach, intestinal or bowel problems?*

YesNo
Do you suffer kidney or bladder problems?*

YesNo
Do you have any skin disorders especially effecting the hands, arms or face?*

YesNo
Do you suffer from boils, styes or septic fingers?*

YesNo
Do you have varicose veins which cause trouble?*

YesNo
Do you suffer from back problems (previous or current)?*

YesNo
Do you suffer from rupture or hernia?*

YesNo
Do you have a skin condition that may result in the need for you to wear gloves?*

YesNo
Have you had Typhoid, Paratyphoid, Dysentery, Salmonella infection or suffer with recurring diarrhoea or vomiting?*

YesNo
Are you on medical treatment at present?*

YesNo
ALLERGENS: Peanuts, Milk (lactose), Egg, Fish, shellfish, cereals (containing Gluten, Rye, Barley, Oats, Spelt,Kumat), Celery, Celeriac, Mustard, Sesame seed, Sulphur Dioxide or Sulphites, Soya, Lupin, Tree Nuts (Walnut, Almond, Cashew, Pecan, Brazil, Pistachio, Macadamia, Queensland)
Do you have any allergies or are you aware of having any reactions to the allergens listed above?*

YesNo
Please tick the allergens where applicable

PeanutsMilk (lactose)EggFishShellfishCereals (containing Gluten, Rye, Barley, Oats, Spelt,Kumat)CeleryCeleriacMustardSesame SeedsSulphur Dioxide or SulphitesSoyaLupinTree Nuts (Walnut, Almond, Cashew, Pecan, Brazil, Pistachio, Macadamia, Queensland)
Have you had a tetanus injection in the last 10 years?*

YesNo
When was your last tetanus injection?

MonthDayYear
Date
Are you a registered disabled person?*

YesNo
If you are a registered disabled person, please give you registration number?
Finally may we remind you that:

1) You must not wear jewellery in the factory areas (Ethnic, religious or medical jewellery must be authorised by the QA department)

2 ) No photographic equipment may be taken into production without the authorisation of a director.

3) The factory protective clothing code must be observed at all times.

I confirm that / have read and understood the "Hygiene Rules" and that the above answers are a true statement:
Signed*

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Checked
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PERSONAL HEALTH QUESTIONNAIRE