North East Arnhem Land Medical Questionnaire

The purpose of this form is to indicate if you have any medical condition which may be aggravated while you will be participating in your North East Arnhem Land secondment. The information may be helpful in determining any assistance that can be provided to you to ensure your health and safety whilst on secondment.

The personal information that you provide on this form is protected by privacy laws. Access to this information is available to yourself and the North East Arnhem Landcontact, and is confidential. Any information collected or disclosed by us will only be used for the purposes of determining the effect of any illness or injury on your ability to perform your work duties whilst on secondment.

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Please answer the following questions (please use red font):

  1. Will you be required to take any medication during your secondment? Yes / No

Details:______

  1. Do you or have you had any pre-existing medical condition that might impact on your ability to undertake the activities included in the program? Yes / No

Condition / X if applicable / Condition / X if applicable
Back or neck pain / surgery / Anxiety / Depression
Heart condition / Post traumatic Stress Disorder
Asthma / Counselling for an emotional or psychological consideration or traumatic event
Diabetes / Physical disability
High blood pressure / Skin condition (such as dermatitis, eczema etc)
Epilepsy / Other medical condition

If yes to any of the above, please advise of date of injury / preventative strategies and management requirements:______

______

  1. Are you pregnant? Yes / No

Details: ______

  1. Do you have any allergies to the following:

Allergy / X if applicable / Allergy / X if applicable
Medications / Pollen or flower products
Animals / Environmental
Bee Stings / Foods
Other insects / Other

Please rate the seriousness of your allergy as:

Minor- causes some discomfort but easily controlled by over the counter drugs

Moderate- causes considerable discomfort and requires prescription drugs

Serious- potentially life threatening without urgent medical intervention

Please provide details of any allergy the might require medical attention: ______

______

  1. Do you require any medications to be refrigerated? Yes / No

If yes, please give details: ______

  1. Do you have any specific dietary requirements? Yes / No

If yes, please give details: ______

  1. Do you have any other health / welfare considerations you think may be relevant regarding your secondment? Yes / No

Please advise: ______

______

Please insert name and date and return the completed form to

Please also email to Vit Koci,if you are from WESTPAC

The information provided by me on this form is correct, to the best of my knowledge.

Full Name: ______

Signed: ______

(please physically sign then scan and email this form)

Dated: ___/___/_____

WH&S

Please note that whilst you are on secondment, as you are still paid by your main employer, you will be covered by their relevant WH&S policies. Please familiarise yourself with your organisation’s WH&S policies and refer any questions to your company contact or HR department

If you have any questions or queries about this form, please contact Sandy Hoelscher and/or your company WH&S representative.

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