Medical Questionnaire Form
Kirklees Light Railway Company Ltd
Confidential – Only for use of the Company Medical Practitioner or other Medical Advisor.
IMPORTANT. This questionnaire is to assess any potential health hazards that you may have as a result of any illnesses or disabilities. The report will be seen either by the Company Medical Practitioner or other Medical Advisor who will advise management of any potential problems that could occur which would interfere with the safe operation of the Railway.
Due to the safety critical nature of voluntary roles at the Kirklees Light Railway you MUST declare all medical conditions whether physical or mental. Any diagnosed condition that is not disclosed at this stage may jeopardise volunteer activities at the railway.
The questionnaire is comprehensive and will cover all grades of persons who work on the Railway through the standards of fitness required will vary from job to job. In some situations it may be necessary to contact your General Practitioner, but it would be with your permission
SURNAME ………………………………… Title………………………………………
Forenames………………………………… Date of Birth……………………………
Address …………………………………………...
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Post Code …………………………………………
Home phone number……………………………
Mobile phone number…………………………..
Work Phone number…………………………….
Voluntary Role…………………………………………………………………………..
Name and Surgery Address of General Practitioner……………………………………....
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Post Code…………………………………………
Telephone Number (inc STD)……………………………………………………………………..
Do you, or have you, suffered from any of the following, except for short periods. Please circle the answer you wish to give
- Any problems with your chest, e.g. Recurrent Bronchitis, Asthma?...... Yes/No
- Blood pressure, angina or any heart condition?...... Yes/No
- Fits, fainting, dizziness, blackouts or any other disease of the nervous system?...... Yes/No
- Any problems with your stomach or abdomen?...... Yes/No
- Any condition affecting the throat, ear or eyes?...... Yes/No
- Any defect of vision?...... Yes/No
- Do you wear glasses? (Date of last examination…………………………)...... Yes/No
- Do you have any colour blindness?...... Yes/No
- Do you have any hearing problems?...... Yes/No
- Do you wear a hearing aid?...... Yes/No
- Diabetes?………………………………………………………………Yes/No
- Do you have a Hernia?...... Yes/No
- Back problems including discs, Arthritis, Gout, Rheumatism?...... Yes/No
- Any physical deformity?...... Yes/No
- Any mental illness, e.g. depression, anxiety, severe stress or alcohol related problems?...... Yes/No
- Have you been diagnosed with any non physical disabilities (eg Autistim, Aspergers, ADHD)…Yes/No. If Yes, please provide details below.
- Any other illness or condition not already mentioned?……..…Yes/No
- Any condition that prevents or would prevent you from holding a car drivers licence?...... Yes/No
If you answer YES to any of the above, please give details below also any other relevant information:
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If you are taking any medication, please list below:
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PLEASE READ CAREFULLY BEFORE SIGNING
- I declare that the above answers are to the best of my belief, true and correct in every respect.
- I give the Company Medical Adviser permission to contact my own General Practitioner for further particulars of my medical records if this should prove necessary.
- I agree to undergo a medical examination if this is required before working in a specific role on the railway or if there is a legal requirement.
Signed…………………………………………………………………………………….
Date………………………………………………………………………………………..
When this form is completed, please put in a sealed envelope. Please mark with your name and “Medical Questionnaire Confidential”
Thank you for your cooperation