F-CG-007

/

OPTIMA HEALTH

/

F-CG-007

Issue 2 – 07/05/13 Reviewed Feb 2015

LIFT TRUCK OPERATORSHEALTH QUESTIONNAIRE

SECTION 1 - PERSONAL DETAILS

Company/Organisation ………………………………………………………………………… / Location: ......
SURNAME ……………………………………………………………………………………………… / FORENAMES ……………………………………………………………………………………………
Mr/Mrs/Miss/Ms/Title ……………… / Sex: Male / Female / Date of birth:
Job title: ......
Date commenced present job: ...... / GP name: Dr ………………………………………………………………………………….
Home address ...... / GP address: …………………………………………………………………………………………......
…………………………………………………………………………………………… / ………………………………………………………………………………………… ......
Postcode ...... / Postcode ......
Telephone No: …………………………………………………………………………………………… / Telephone No: …………………………………………………………………………………......
DATA PROTECTION ACT 1998
Personal information generated by completion of this form provides a medical view of your fitness for employment or specific task. Without this information your application/assessment of fitness will not proceed further. The Occupational Health Adviser or Occupational Physician may require further information about your health before coming to a view on your fitness. Your consent to further reports from your medical advisers will be sought in these circumstances before a certificate of fitness/restrictions/unfitness can be issued. All such medical information will be kept in strict medical confidence by the Occupational Health staff. Your consent will be sought for any other use of all or part of this confidential medical data.
On this form you will be asked a number of questions about your health. The information obtained will be available only to medical personnel and held as medical in confidence. Medical details which you give will not be released to an employer without your explicit consent.

SECTION 2 - QUESTIONNAIRE

/ Yes / No / Details
Give full information where applicable
1.  / Do you hold a current valid driving licence? / …………………………………………………………………………………………
2.  / Have you consulted a doctor/health practitioner or been referred to hospital in the last 2 years? / …………………………………………………………………………………………
3.  / Are you restricted for medical reasons from
carrying out any particular type of work?
(If so, state what) / …………………………………………………………………………………………
4.  / Are you currently taking any form of medication?
(If so, please state name of medication, date first prescribed and dosage.) / …………………………………………………………………………………………
5.  / Have you been dependant on alcohol
or illegal drugs? / …………………………………………………………………………………………
6.  / Do you currently take illegal drugs? / …………………………………………………………………………………………
7.  / Have you had any heart trouble,
eg heart attack, angina, palpitations? / …………………………………………………………………………………………
8.  / Have you been diagnosed as having
high blood pressure? / …………………………………………………………………………………………
9.  / Have you had any fainting attacks, fits, stroke, blackout or unexplained loss of consciousness? / …………………………………………………………………………………………
SECTION 2 - QUESTIONNAIRE CONTINUED / Yes / No / Details (Give full information where applicable)
10.  / Do you have attacks of dizziness, giddiness
or disturbance of balance? / ......
11.  / Do you have diabetes? / ......
12.  / Do you have difficulty hearing? / ......
13.  / Do you have any visual impairment? / ......
14.  / Have you had any trouble with your nerves
or had a nervous breakdown? / ......
15.  / Have you had treatment from a psychiatrist, psychologist or counsellor? / ......
16.  / Have you had persistent or recurrent low back pain? / ......
17.  / Have you had persistent or recurrent
neck or shoulder pain? / ......
18.  / Have you had recurrent pain in your arms,
hands, legs or joints? / ......
SECTION 3 - DECLARATION - I hereby declare that all medical information given by me to Optima Health is true and accurate to the best of my belief and knowledge.
Signature of Applicant / ...... / Date / …………………………………………………………
SECTION 4 - HEALTH ASSESSMENT
Height (in centimetres) ...... / Weight (in kilogrammes) ......
Blood pressure ...... / Pulse......
Body Mass Index (BMI)………………
Vision screening: / Acuity / £ Acceptable £ Unacceptable / ......
Colour vision / £ Acceptable £ Unacceptable / ......
Visual fields / £ Acceptable £ Unacceptable / ......
Mobility: / Spine / £ Acceptable £ Unacceptable / ......
Upper limbs / £ Acceptable £ Unacceptable / ......
Lower limbs / £ Acceptable £ Unacceptable / ......
Hearing / Warble Tone Results: / ü = Heard / û = Not heard
Warble Tone / £ Yes / £ No / Left ear frequencies / Right ear frequencies
1 kHz / 2 kHz / 4 kHz / 1 kHz / 2 kHz / 4 kHz
Whisper Test / £ Yes / £ No / *30dBHL
*50dBHL
£ Acceptable £ Unacceptable / * dBHL freefield at 50cm using CE70 audiometer
ASSESSMENT SUMMARY
£ SUITABLE FOR WORKING WITH LIFT TRUCKS / £ NOT SUITABLE FOR WORKING WITH LIFT TRUCKS
£ FURTHER ASSESSMENT REQUIRED
Signature of examiner ………………………………………………………………………… / Position ……………………………………………………………………………………………………
Date ……………………………………………………………………………………………………………… / (BLOCK LETTERS)

Page 2 of 2

Optima Health In Confidence