occupational-health-questionnaire – On Track Care Services

Any mental illness or psychological problems e.g. depression nervouse breakdowns, eating disorder, substance misuse or other?

Yes No Don't know

A drug or alcohol problem?

Yes No Don't know

Fits, blackouts or epilepsy?

Yes No Don't know

Any allergies?

Yes No Don't know

Asthma, bronchitis or chest problems?

Yes No Don't know

Treatment for TB?

Yes No Don't know

In the last 12 months have you had a cough for more than 3 weeks, ever coughed up blood or had any unexplained loss of weight or fever?

Yes No Don't know

Diabetes, thyroid or gland problems?

Yes No Don't know

Any illness which may have caused or been made worse by your work?

Yes No Don't know

Episodes of chest pain or breathlessness?

Yes No Don't know

Suffer from heart disease or high blood pressure?

Yes No Don't know

Are you at present taking or receiving any form of medication?

Yes No Don't know

Any operations?

Yes No Don't know

Been retired on the grounds of ill health?

Yes No Don't know

Are you waiting for or receiving treatment for any medical or mental health

Yes No Don't know

Have you ever suffered with stress associated with work?

Yes No Don't know

Is there any additional relevant information regarding your health not covered in the above questions?

Yes No Don't know

Any skin conditions? (please specify)

Yes No Don't know

Hepatitis or jaundice? *

Yes No Don't know

Dysentery, typhoid, paratyphoid, fever, food poisoning, salmonella, severe gastroenteritis or diarrhea? *

Yes No Don't know

Any discharge from ears or current/recurrent ear infections? *

Yes No Don't know

How many days have you lost from work or school during the past year?

What was this due to?

HB test (Heaf, Tine, Mantoux)

Yes No Don't know

BCG [TB vaccinations]

Yes No Don't know

Tetanus

Yes No Don't know

Poliomyelitis

Yes No Don't know

Rubella [German Measles]

Yes No Don't know

Hepatitis A

Yes No Don't know

Hepatitis B (Date of last immunisation)

Yes No Don't know

Meningitis B

Yes No Don't know

Hepatitis B

Yes No Don't know

Rubella [German Measles]

Yes No Don't know

Varicella (Chicken pox)

Yes No Don't know

Chest X-ray [clear)?

Yes No Don't know

The company operates a policy of non-discrimination. In line with company policy, and National Guidelines, 'HSC 1998/226 - Guidelines on the Management of AIDS/HIV Infected Health Care Workers and Patient Notification' (updated August 1999), you must inform the Director of Training and Quality if you know or suspect you are HIV positive or have an AIDS defining illness. This information is necessary in order that a Risk Assessment may be undertaken to your safety and that of others. If you know or suspect you are either HIV antibody positive or have AIDS, please tick the appropriate box. This information is absolutely confidential to the Director of Training and Quality.

Yes No Don't know

The following section is to be completed only by those members of staff who regularly undertake night duty. Have you suffered from and been treated for any of the following. If Yes, please give details of the condition and whether they are ongoing at present.

I Understand

Blackouts/Fainting fits/Epilepsy

Yes No Don't know

Back or limb disorders

Yes No Don't know

Diabetes

Yes No Don't know

Heart or circulatory disorders

Yes No Don't know

Stomach, bowel or intestinal disorders

Yes No Don't know

Any conditions affecting sleep

Yes No Don't know

Asthma/ bronchitis

Yes No Don't know

Nervous or mental disorders

Yes No Don't know

Serious operations/accident/injuries

Yes No Don't know

Do you have any other ongoing health problem?

Yes No Don't know

Are you currently taking drugs or medicines prescribed by a doctor or purchased from a pharmacy?

Yes No Don't know

Do you consider that you have any form of medical condition that may affect your ability to work at night?

Yes No Don't know

Have you ever felt that night work was harming your health?

Yes No Don't know

Do you wish to discuss anything with a health advisor?

Yes No Don't know

Declaration I declare that the information on this form is true to the best of my knowledge. Further, I understand that if I should be found to knowingly make a false statement regarding my medical history either in answering the above questions or to the Company's Director of Quality and Training, or should I conceal any material fact, the Company can terminate my contract without notice.

I Agree and Understand the terms and condition.

Occupational Health Questionnaire

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