Research Degrees
Medical form
What this form is for
For full-time research students to provide details of any medical
conditions for Occupation Health purposes
Who should complete it
Full-time research students who will be studying on the Milton Keynes campus
How it should be
submitted
You can click on the grey boxes to complete this form electronically, then email
this form to Occupational Health at Occupational-Health-AndSafety@open.ac.uk Do not send it to the Research Degrees Office.
The information on this form will remain confidential to the Occupational Health
Department and will only be used to ensure the appropriate steps are taken to
protect your health while on campus.
1
Your details
Title:
Your full name:
Date of birth:
/
/
DD/MM/YY
Residential address:
Postcode:
Phone number:
Email address:
Department:
2
Emergency
contacts
Please provide details of two people who may be contacted in an emergency:
Name:
Address:
Phone number (home):
Phone number: (mobile):
Phone number (work):
Email address:
Relationship to you:
Name:
Address:
http://www.open.ac.uk/research/research-degrees/forms-and-guidance-notes.php
Phone number (home):
Phone number: (mobile):
Phone number (work):
Email address:
Relationship to you:
3
Your health
Have you any history of the following? If ‘Yes’, please give details, including
dates and how you are now.
Fits, fainting, giddy spells,
blackouts or epilepsy?
Yes
No
Details:
Heart disease?
Yes
No
Details:
Chest complaints (e.g. asthma,
TB)?
Yes
No
Details:
Allergic conditions (e.g. hay
fever)?
Yes
No
Details:
Skin conditions (e.g. eczema,
psoriasis)?
Yes
No
Details:
Diabetes?
Yes
No
Details:
Back pain or injury (at home or
work)?
Yes
No
Details:
Wrist, arms, shoulder or neck
pain?
Yes
No
Details:
Any illness or injury due to work?
Yes
No
Details:
Any nervous disorder or
psychiatric illness?
Yes
No
Details:
Have you consulted your doctor or
hospital specialist in the past two
years?
Yes
No
Details:
Are you taking any medicines or
undergoing any treatment at
present?
Yes
No
Details:
Do you have a disability?
Yes
No
Details:
Have you had any treatment in
hospital, including operations or
treatment for accidents?
Yes
No
Details:
Have you attended hospital as an
outpatient?
Yes
No
Details:
Have you had an eye test
specifically for display screen
work?
Yes
No
Details:
Do you wear glasses solely for
Yes
No
Details:
2
display screen work?
4
Any other
information
Your height:
Your weight:
Are you vaccinated against:
Polio?
Yes
No
Tetanus?
Yes
No
Hepatitis B?
Yes
No
Have you had any other vaccinations in the last 10 years?
What kind of work will you primarily be doing on campus (e.g. lab work, field
work, desk work)?
Any other medical information you want to mention:
3