PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2016

PART A–Applicant Personal Information

PART B – Applicant General Health Information

PART C – Applicant Medical History

PART D – Applicant Vaccination and Immunisation History

PART E – Applicant Declarationto be signed and dated

Please complete all the relevant parts with as much information as possible. Your completed questionnaire with health details is required to enable the Occupational Health screening provider to complete an assessment of your health and well being in relation to your proposed course, your ability to perform this role and whether any adjustments or provision of equipment or aids will be required in order for you to perform this role.

All information provided in this document will be held by the company contracted by Cardiff Metropolitan University to undertake the screening and will remain confidential and is subject to the provisions of the Data Protection Act 1998. The Occupational Health screening provider will be the custodians of the documents and they will be governed by medical records confidentiality.

Information from this form will only be released with the individual’s written consent.

Please refer to the information at: whilst completing this form.

PART A –Applicant Personal Information

Surname: / First Name(s): / Title:
Mr / Mrs / Miss / Ms /

Male / Female

/ D.O.B. / National Insurance No.
Home Address:
Postcode: / Tel (Home):
Mobile:
E-mail: / GP Details: Dr
Address:
Tel No:
Course Applied For:
Start Date: / Location/Department: / Course Supervisor:
(if known)

PART B – Applicant General Health Information

Any issues or queries requiring clarification will be discussed at your Occupational Health appointment.

Please answer the following questions as accurately as possible.

Please deleteas appropriate

Are you currently exposed to latex?Yes/No

If yes give details, e.g. wear gloves daily.

Have you been diagnosed with a latex allergy?Yes / No

If yes please give details:

Has any employment ever been terminated on health grounds?Yes / No

If Yes please give details:

Do you have any disability you wish to disclose in order that
assistance or help with modifications to your workplace can be provided?Yes / No

If Yes please give details:

PART C – Applicant Medical History

Do you have or have you had any of the following? Please place a tick in the yes or no box, and if you answer yes then please give further details.

CONDITION

/ YES / NO / DETAILS (dates, treatments, medications)
Back problems
Prolonged pain or injury to neck or shoulders
Problems with your hands, arms, legs or feet
Rheumatism, arthritis or other joint problems
Migraine or frequent headaches
Fits, epilepsy, fainting or giddiness
Psychiatric illness or nervous conditions. Depression or anxiety
Disease of the nervous system, e.g. multiple sclerosis
Heart Disease, angina, raised blood pressure
Asthma, bronchitis, pneumonia, TB or chest disease
Breathlessness, palpitations, swelling of the ankles
Frequent bouts of Cystitis, bladder or kidney disease
Frequent indigestion, stomach or bowel disorders

CONDITION

/ YES / NO / DETAILS (dates, treatments, medications)
Hernia, rupture or varicose veins
Diabetes, thyroid or gland disease
Jaundice or hepatitis
Recurrent tonsillitis, sinusitis or hay fever
Discharging ears, perforated eardrum, or hearing impairment
Frequent/recurrent eye infections
Dermatitis, eczema, or other skin complaints
Have you ever had chicken pox or shingles?
Have you ever had measles or mumps?
Have you ever been treated for any drug or alcohol addiction, or eating disorders?
Are you allergic to any food, drug, chemicals or any other materials?
Have you ever attended hospital as an in/out patient? Please specify?
Have you had any defect of sight, do you wear spectacles or contacts?
Have you had more than 2 weeks sickness absence from work / school within the last 2 years?

PART D – Applicant Vaccination and Immunisation History

It is a pre-requisite that you obtain from your GP a print out of all your inoculations from birth to date. Once obtained please attach a scanned copy along with this completed form and email direct to Fulcrum Reporting Limited.

Please note:

If you have had any inoculations at school or elsewhere, you will also need to obtain these and attach a scanned copy as above.

It is very important for those students who are to perform exposure prone procedures to make Fulcrum Reporting Limited aware if they have tested positive or have never been tested for any transmissible blood-borne virus infection, e.g. Hepatitis B or C, or HIV.

Have you ever tested positive for any blood-borne virus infection?

(please tick relevant box) /

Yes

/

No

/

Never Tested

/

Date(s)

/

Management/Treatment

Have you had / Yes / No / Year
TB Immunity Test (Mantoux)
BCG Inoculation
A course of
Hepatitis B Inoculations / 5 Year Booster Due:
Hepatitis B Antibody Test / ………….miu/litre (lab report – enclose copy if possible)
Measles/Mumps/Rubella
Inoculations x2
Rubella Antibody Test / Immune / Non-immune (lab report– enclose copy if possible)
Diptheria/Tetanus/Polio
Inoculations
Meningitis C Inoculation
Any other inoculations, please state

PART E – Applicant Declarationto be signed and dated

Please read the declaration below and sign and date that you have understood it. Your completed form and scanned inoculation documents must be emailed to by the required deadline for your course.

  1. I declare that the information given in this document is true and complete to the best of my knowledge, and I understand that failure to disclose information may affect my acceptance onto the course.
  2. I consent to a medical examination if necessary and that relevant details and results of any tests may be sent to my General Practitioner.
  3. I agree to undergo blood tests and accept inoculations necessary to undertake the duties of the course.
  4. I have obtained a printout of my vaccination history and attached it to this form.

Signature:……………………………………..Date:……………………………