Offshore -OEUK (engelsk)

OEUK
Name

Given namesSurname
Email
example@example.com
Phone

Area CodePhone Number
Date of birth

MonthDayYear
Date
Nationality
Offshore Occupation / job title
Employing company
Date of last offshore medical

MonthDayYear
Date
Fireteam member
Do you smoke if so how many pr day
If an exsmoker when did you quit
Average onshore weekly alcohol consumption in units
OCCUPATIONAL HISTORY
Have you been exposed to any known occupational hazards such as noise radiation dust asbestos chemicals or lead?
Have you used protective clothing safety glasses and hearing protection?
Have you ever developed any medical condition in connection with your occupation?
Have you suffered any industrial injury If so please give details?
Have you ever been rejected from employment on medical grounds?
Have you received compensation or is there any industrial claim pending?
Have you ever been evacuated for emergency medical reasons from an offshore installation?
Are you taking any medication?

Rows	Yes	No
Chest pain/ heart pain/ heart attack?
High Blood Pressure?
Stroke?
Asthma?
Epilepsy?
Diabetes?
Pectic ulcer disease?
Mental problems e.g. anxiety/depression?
Kidney disease?
Tuberculosis or other infectious diseases?
Cancer?
Have you been to hospital within the last 5 years?

Rows	YES	NO
Backpain/joint pain (muskel og ledsmerter)?
Hernia (brok)?
Eye problems (apart from glasses)?
Gastritis?
Hepatitis or gall bladder disease?
Change in bowel habit/ diarrhea?
Blood in stools/piles, haemorrhoids?
Shortness of breath?
Recurrent bronchitis/pneumonia (bronkitis eller lungebetændelse)?
Blood in urine or kidney stones?
Headaches/migraine/dizziness?
When did you last see a dentist?

OEUK