PRE-PLACEMENT HEALTH DECLARATION
This form is to be filled out by you the candidate and returned to: The Occupational Health Nurse, Occupational
Health Department. Please ensure ALL questions are answered in full.
The completed form will be kept confidentially in the Occupational Health Department.
Your Name ________________________________________
Date of Birth:________________
Your address:_____________________________________________________________________
Phone no: (mobile & home):________________________________________________________
Current position:________________________________________________________________________
Name and address of your own Medical Examiner (G.P.): ________________________________
___________________________________________________________________________________________
Date when you last attended any Doctor / Medical Examiner: _____________________________
Reason for this attendance: _________________________________________________________
__________________________________________________________________________________
Do you have any problems, or have you had any problems in the past with the following: (Please tick appropriately)
Standing
Yes
___
No
___
Bending
Yes
___
No
___
Working at heights
Yes No
___ ___
Walking
___
___
Moving your neck or back
___
___
Climbing Stairs
___ ___
Lifting
___
___
Using your hands or elbows
___
___
Using your legs or feet ___ ___
___
___
Have you ever attended a manual handling training course?
PLEASE ANSWER ALL OF THE FOLLOWING
QUESTIONS.
How many times have you visited your doctor in the last year?
How many days have you missed from Work/School/College in the
past 3 years due to injury or illness?
Do you smoke?
If yes, please state how many per day
Do you drink alcohol?
If yes how much per week?
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Please Give details
HEALTH DECLARATION - (To be completed by candidate)
Today’s Date:
Your Name:
Yes No If Yes, give full details
Do you suffer from now or have you ever had: Any health difficulty with working at night or with shift work?
Insomnia/Sleeping problems?
Any Infectious Diseases / Tropical Diseases / Malaria / HIV
AIDS / Hepatitis B or Hepatitis C ?
Liver / Bowel / Stomach / Gallbladder/ Pancreatic
problems?
Anaemia / Jaundice / Sickle Cell Disease / Blood
Diseases?
Any disease or injury arising out of work?
Have you ever been in hospital as an Inpatient / Outpatient
/ Day case?
What operations have you had?
(Please list all or write none if appropriate)
Any numbness or loss of sensation in any body part?
Any fatigue syndrome e.g. Post Viral Fatigue, M.E.,
Burnout?
Allergies of any type, including Hayfever, Drugs, Food,
Latex or any other item? Or Any Work related Allergies?
Mental Health or Psychiatric problems e.g. Anxiety, Panic
attacks, Depression, Nervous breakdown, Stress, Bullying
or an attendance with a Psychiatrist.
Heart trouble/ Circulatory disorders
E.g. high blood pressure, heart murmur, heart attack, blood
clots?
Glandular problems e.g. Diabetes/ Thyroid problems?
Kidney problems, e.g. infections / stones, or kidney failure?
Disorders of the nervous system. e.g. Fits, Blackouts,
Migraine, Severe headaches, Stroke?
Any history of substance / drug / alcohol abuse?
Skin problems, e.g. moles, eczema, dermatitis, psoriasis,
excessive sweating, boils?
Neck, back or joint problems, e.g. muscular soft tissue,
whiplash, disc problems, sciatica, limb pain, arthritis, gout.
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HEALTH DECLARATION - (To be completed by candidate)
Today’s Date:
Your Name:
Yes
No
Repetitive strain injury (RSI), tendonitis, overuse injury?
Ears, nose or throat problems? Hearing problems?
Tumors, benign or malignant?
Eye problems / treatment, colour blindness.
Lung or chest problems e.g. asthma, T.B. bronchitis,
pneumonia?
Any exposure/treatment for a blood Borne virus exposure?
OCCUPATIONAL HISTORY:
Please list and provide details of your past work history starting with your most recent job
Dates
From
INDICATE WHETHER ANY EXPOSURE TO
Infectious diseases, blood borne Viruses,
sharps injuries, chemicals, other hazards.
Organisation
To
MEDICATIONS:
Please list all medications you are taking currently or have taken in the past 3
months
(Include inhalers, sprays, creams, herbal, homeopathic and over the counter
preparations)
Write none if you are not taking any medication:
________________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________
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HEALTH DECLARATION - (To be completed by candidate)
Your Name:
Today’s Date:
IMMUNISATION DETAILS:
You are required to provide documented evidence that you have received the following;
o Primary Childhood Vaccinations-including meningitis vaccination (Men C).
o 2 MMR’s & dates received.
o BCG vaccination.
This information should be available from your General Practitioner and/ or the HSE schools immunisation
department.
TUBERCULOSIS
Symptoms of TB can include any of the following:
Fever and night sweats, Cough (generally lasting more than 2 weeks), Weight loss, Blood in the sputum
(phlegm) at any time. A Healthcare worker with any of these symptoms should seek an appointment with
Occupational Health or their family doctor for advice.
Have you BCG marks/scars?
YES / NO
Where are the scars?_____________
Have you had a Recent Mantoux test?
YES / NO
When & Result:___________________
Have you had any recent contact with TB?
YES / NO
Details:__________________________
Have you any suspicious symptoms of TB?
YES / NO
Details:__________________________
(E.g. Cough, fever, chills, night sweats, weight loss, sputum production, haemoptysis)
Date Of last Chest X-Ray:____________________ Result:________________________________________
DECLARATION:
I hereby certify that I personally completed this questionnaire. The answers to these questions are accurate to the
best of my knowledge.
I agree to undergo such medical surveillance as considered appropriate by the HSE West Area’s Occupational
Health Service.
Signature of Candidate: __________________________________________ Date: ________________
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