• YEHS

    YEHS

  • YEHS - F2W Quest and Exam Form

    plus Audio and DAT

  • This form is to be used for 

    • New / First GP Patient Appointments
    • Other Generic Fitness Assessments
    • Canada Staff / Driver Medicals
    • OEUK (if the specific form is not indicated)
  • When is your appointment
     - -

  • YOUR PERSONAL DETAILS

  • Date of Birth
     - -
  • Format: 00000-000-000.

  • YOUR USUAL DOCTOR

  • In the course of this assessment, we might need to contact your doctor to obtain more information or a medical report. Information requested will be relevant only to this assessment.

  • Do you consent to this
  • Format: (000) 000-0000.

  • YOUR WORK

  • Format: (000) 000-0000.

  • YOUR PREVIOUS MEDICALS

  • 1. Date
     - -
  • 2. Date
     - -
  • 3. Date
     - -

  • YOUR SOCIAL AND OCCUPATIONAL HISTORY

  • 1. Do you smoke?
  • 4. Have you ever been exposed to any known Occupational hazard such as noise, radiation, dust, asbestos, chemicals or lead?
  • 5. Do you use protective clothing, safety glasses or hearing protection?
  • 6. Have you ever developed any medical condition in connection with your occupation? If yes, plese give details
  • 7. Have you ever suffered any industrial injury? If so, please give details
  • 8. Have you ever had any previous audiometric screening? State when, where and if it was normal/abnormal
  • 9. Have you ever had previous lung function screening? State when, where and if it was normal/abnormal
  • 10. Have you ever been rejected from employment on medical grounds?
  • 11. Have you ever received compensation or is there any industrial claim pending?
  • 12. Have you ever been evacuated on medical grounds from an offshore installation?
  • 13. Have you ever been evacuated on medical grounds from any other facility?

  • Your Medical History

    Do you have or have you been diagnosed as suffering from any of the following?
  • 1. Chest pain/heart pain
  • 2. High blood pressure/Stroke
  • 3. Asthma/epilepsy/diabetes
  • 4. Peptic ulcer disease
  • 5. Kidney disease (e.g stones)
  • 6. Psychiatric disorder (eg anxiety, depression)
  • 7. Tuberculosis
  • 8. Cancer
  • 9. Palpitation
  • 10. Joint pain or swelling
  • 11. Recurrent neck pain

  • Do you currently have any of the following?
  • 1. Backache/joint or muscular pain
  • 2. Hernia/rupture
  • 3. Visual impairment
  • 4. Perforated eardrum/discharge from ear
  • 5. Recurrent indigestion
  • 6. Jaundice/hepatitis/gall bladder disease
  • 7. Change in bowel habit/diarrhoea
  • 8. Blood in stools/piles/haemorrhoids
  • 9. Shortness of breath/coughing up blood
  • 10. Recurrent bronchitis/pneumonia
  • 11. Blood in urine/kidney complications/stones
  • 12. Headaches/Migraine/dizziness

  • YOUR PHYSICAL FITNESS TEST (CARDIOVASCULAR/MUSCULOSKELETAL SCREENING TOOL)

    Positive answers to any of the above questions may require referral to a physician for further consideration and investigation prior to clearance to participate in the aerobic capacity assessment.

  • Do you have or have you been diagnosed as suffering from any of the following?
  • 1. Coronary artery disease
  • 2. Angina
  • 3. Heart attack/myocardial infarction
  • 4. Aortic aneurysm
  • 5. Heart Failure
  • 6. High blood pressure
  • 7. Cardiac arrhythmia
  • 8. Cardiomyopathy
  • 9. Osteoarthritis
  • 10. Cardiomyopathy
  • 11. Other joint or bone disease

  • Have you ever undergone any of the following?
  • 1. Coronary artery bypass
  • 2. Coronary angiogram
  • 3. Pacemaker Insertion
  • 4. Implanted cardiac defibrillator
  • 5. Joint replacement or other joint surgery
  • 6. Are you regularly taking any medication?
  • Do you have any other concerns about your Ability to carry out a physical fitness test?

  • TEST CANDIDATE DECLARATION

    | certify that the above information is correct and I am aware that giving false information or a failure to declare a known condition or any current / on-going medical investigation which may result in risk or harm being put to colleagues at theworkplace may lead to disciplinary action.
  • Should be Empty: