Occupational Health Questionnaire

PERSONAL INFORMATION

Name:

/ Employee number:

Address:

Telephone no:

/ Work: ( ) Home: ( ) Cell:

Sex:

/

Male Female

/

Marital status:

Age:

/ /

Date of birth:

Who will be your immediate superior?
In which department are you employed?
Date on which you commenced duty?
What is your occupation?

OCCUPATIONAL HISTORY

  1. Have you been exposed to any chemical at home or at your previous position of employment during the past three months? Yes No

Specify: ……………………………………………………………………………………………………..……..

  1. If “yes”, has any medical test been carried out? Yes No ………………………………..……………...
  2. Prior exposure to health hazards (e.g. Asbestos) ……….……………………………………………...

Childhood - Pre-school …………………………………………………………………………………..

During school .……………………………………………………………………………………..

Post-school …………………………………………………………………………………………...

  1. Employment history regarding exposure to hazards

Company / Dates / Occupation / Hazard exposure




MEDICAL HISTORY

NAME OF HOME DOCTOR / ADDRESS / CONTACT DETAILS

SPORTS AND HOBBIES:

…………………………………………………………………………………………………………………

SOCIAL HABITS:

Smoking: Yes NoIf ‘yes”, number per day …………year…………..

Consumption of alcohol: Yes NoType: …………… Quantity per week: …………………

Have you ever been warned or treated for abuse? Yes No

…………………………………………………………………………………………………………………

If yes, to any of the following, please provide complete details:

  1. Heart disease, e.g. rheumatic fever, disease of coronary artery, chest pain, shortness of breath, palpitations, high blood pressure, affection of the blood vessels or circulation. Have you had any special examination, e.g. ECG?
/ Yes No
………………………………………………………………………………………………………………………
  1. Respiration or lung problems e.g. asthma, bronchitis, constant cough, tuberculosis, special examination e.g. X-rays?
/ Yes No
………………………………………………………………………………………………………………………
  1. Affection of the digestive tract e.g. gall-bladder or liver, stomach or duodenal ulcer, indigestion or hernia, jaundice, vomited blood or piles. Special examination e.g. gastroscopy?
/ Yes No
………………………………………………………………………………………………………………………
  1. Affection of the kidneys, bladder or genitals e.g. blood in urine, prostatitis or venereal diseases. Special examination e.g. renal arteriogram, intravenous pielogram (IVP)?
/ Yes No
………………………………………………………………………………………………………………………
  1. Affection of the muscles, joints, limbs, vertebrae e.g. rheumatism, fracture. Any X-rays taken?
/ Yes No
………………………………………………………………………………………………………………………
  1. Affection of the nervous systems e.g. epilepsy, fainting, blackout, paralysis, neurosis or depression? Special examinations e.g. brain scan?
/ Yes No
………………………………………………………………………………………………………………………
  1. Disease of the eyes, ears, nose or throat e.g. defective sight, loss of hearing, perforation of the eardrum. Any special examination e.g. hearing test or vision test?
/ Yes No
………………………………………………………………………………………………………………………
  1. Diabetes, thyroid or other hormonal abnormalities. Special examination e.g. thyroid functions, blood test or glucose tolerance?
/ Yes No
………………………………………………………………………………………………………………………
  1. Cancer, tumour of any kind. Has any examination/operation been done?
/ Yes No
………………………………………………………………………………………………………………………
  1. Affection of the skin or allergies of any kind?
/ Yes No
………………………………………………………………………………………………………………………
  1. Tropical diseases e.g. bilharzia or malaria? Were any diagnostic examinations done e.g. blood tests?
/ Yes No
………………………………………………………………………………………………………………………
  1. Have you had a work injury before; if so, did you receive any compensation for permanent disablement? Has any application for compensation or insurance ever been turned down?
/ Yes No
………………………………………………………………………………………………………………………
  1. Weight: Have you registered any change of more than 3kg during the year? Has your weight declined by more than 5kg during the past three months?
/ Yes No
………………………………………………………………………………………………………………………
  1. Any use of sedatives during the past five years for medical or other reasons? Did this exceed 30 days?
/ Yes No
………………………………………………………………………………………………………………………
  1. Female applicant: Do you suffer from any gynaecological ailments? Are you pregnant; if so, when is your expected date of delivery, if not, date of your last normal menstruation?
/ Yes No
Yes No
………………………………………………………………………………………………………………………
  1. Do any of your relatives suffer from diabetes, affection of the heart, high blood pressure, mental illness, porphyria, epileptic disease, asthma or any other hereditary or chronic illness?
/ Yes No
………………………………………………………………………………………………………………………
  1. If deceased: Age at death and cause of death

Father:
Mother:
Brothers:
Sisters:
  1. Any problems which have not been disclosed?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
19. Allergies:. ………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
20. Current or chronic medication: ………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

DECLARATION BY APPLICANT

I hereby declare that the above medical history is true and that a medical examination has been done at …………………………………….………………… on (date) ………..…………………………….., by Dr/Sr …………………………………………………..

I also declare that I fully understand the content of this document and that my appointment is subject to this result as determined by the Medical Policy.

I herewith give consent to the medical personnel to obtain all medical records which may be relevant, at the time of my appointment, prior to that date and after my appointment.

I hereby commit myself to a healthy and safe way of conduct according to the company’s policy.

I will report all injuries/conditions of illness to the personnel department/medical department as soon as possible.

…..…………………………………………. ……………………………….

SIGNATUREDATE

PHYSICAL EXAMINATION

This page must be completed by the Medical Personnel

Weight (in clothes) / Height (without shoes) / BMI (mass/height)
  1. General appearance (jaundice, anaemia, deformities, etc.): ……………………………………..…. ……………………….………..………………………..……………………………………………………………………………………………………………………………………….…..…………………
  2. Head, face, scalp and neck: ………………………………………………………………………………………………………...
  3. Ear/nose/throat::………………………………………………………………………………………
  4. Dental: ……………………………………………………………………………………………………………
  5. Eyes - Clinical abnormalities:……………….…………………………………………………………………………
  6. Glands……………………………………….……………………………………….……..……………
  7. Dermatological:…………………………………………………………………………………………
  8. Respiratory system: ……………………………………………………………………………………
  9. Endocrine system: Thyroid: …………………………………………………………………………..
  10. Cardiovascular system: BP (sitting):……………… BP (lying):……………. Repeat if over 140/90mmHg: ……………………..

Pulse rate: ………….….. ……… Pulse rhythm:……………………… Heart sound: …………………………………………….

  1. Abdomen:……………………………………………………………………………..…………………
  2. Spine and muscoskeletal …………………..…………………………………………………..……
  3. Psychological impressions: ……………………………………………………………………………
  4. Neurological:

Arms:

Motor system:Strength:…………………….……………… L ……….….. R …….…..….

Reflex:…… ………….…………………… L …….…….. R ….……..….

Sensory system:…………………………… L ……….….. R ….……..….

Range of motion ………………………….. L……………. R…………….

Legs:

Motor system:Strength …………………….……………… L ……….….. R …….…..….

Reflex ………………….…………………… L …….…….. R ….……..….

Sensory system:…………………………… L ……….….. R ….……..….

Range of motion:. ………………………… L……………. R …………….

Ankle reflexes: ……………….. ………… L ……….….. R ….……..….

  1. Genito-urinary system: ………………………………………………………………………………

Urine dipstick test: ...... ………………………………………………………………………

Special examination

See Appendix B for breakdown of high job risk categories

  1. Vision examination:

Spectacles or lenses used:……………………………………………………………………………

Opthalmoscopy: ………………………………………………………………………………………

Visual acuity: R L

Distant 6m Sneller / R 6/ / L 6/
Near 50cm / R / L
Colour vision / NAD / Normal colour vision
Depth / NAD / Normal depth perception
Visual fields / NAD / Normal visual range
  1. Audiometry (see attached audiogram)

Percentage loss of hearing: ……………%

  1. Spirometry test (see attached lung function)

Spirometry test / Actual / Predicted / %
FEV1
FVC
Ratio
Diagnosis:
  1. Blood analysis (see attached report)

Blood glucose / mmol
Cholesterol / mmol
Haemoglobin / mmol
Liver function / NAD
Full blood count / NAD
U&E / NAD
Toxicology lead etc / NAD
Other / NAD
Urine MKS etc / NAD
  1. Rest and Stress ECG (see attached report)

Diagnosis: …………………………

  1. Chest X-ray (see attached report)

Diagnosis: ………………………..

21. Other examinations requested: …………………………………………………………………………

………………………………………………………………………………………………………………

Medical practitioner

I hereby certify that I personally examined the applicant and this report and attachments embody my findings completely and correctly.

The applicant…………………………………… Company number: …………………………………

Name:………………………………………………….……Qualification: …………………..………

Address: …………………………………………………………………………………..……….………

Tel: ………………………….…………. Period you have known patient? ……………………..……..

Able to perform duty without limitations
Able to perform duty, but with reduced efficiency
Able to perform duty, but work will aggravate the medical condition
Able to perform duty, but not without being a risk to himself and others
Totally unable to perform work in question

______

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