Occupational Health Service
FOLLOW-UP RESPIRATORY ASSESSMENT
SECTION A: PERSONAL DETAILS
Mr/Mrs/Miss/Ms/Prof/Dr/Other ............................... Date of Birth ..........................................................
Surname ........................................................ First Name ............................................................
Home Address ................................................................................................................................
....................................................................... Post Code .............................................................
Home tel no .................................................... Work tel no ...........................................................
Department .................................................... Position Staff/student category .............................................
Start Date ...................................................... Registration ..........................................................
SECTION B: PREVIOUS HEALTH SURVEILLANCE
Name of respiratory sensitiser? .......................................................................................................
How often are you exposed to this? ...............................................................................................
When were you last exposed to this? ..............................................................................................
Has there been any change in your work practices since your last assessments? Yes ☐ No ☐
If yes give details .............................................................................................................................
Do you feel well today? ........................................................................................ Yes ☐ No ☐
If no give details ...............................................................................................................................
Do you smoke? ..................................................................................................... Yes ☐ No ☐
Since your LAST Health Assessment have you had any of the following symptoms? (do not include
colds or other respiratory infections)
1. Recurring red, itchy or watery eyes .................................................................. Yes ☐ No ☐
2. Recurring blocked or running nose .................................................................. Yes ☐ No ☐
3. Bouts of coughing ............................................................................................. Yes ☐ No ☐
4. Wheezing ......................................................................................................... Yes ☐ No ☐
5. Breathlessness ................................................................................................. Yes ☐ No ☐
6. Chest tightness ................................................................................................ Yes ☐ No ☐
7. Any skin problems ............................................................................................ Yes ☐ No ☐
If you answered yes to any of the above please give details ............................................................
Have there been any changes in your symptoms since your last Health Surveillance? Yes ☐ No ☐
If yes give details ............................................................................................................................
Do your symptoms improve when you are away from work? ........................................ Yes ☐ No ☐
If yes give details ............................................................................................................................
Have you had time off work due to these symptoms? ................................................ Yes ☐ No ☐
If yes give details ............................................................................................................................
SECTION C: DECLARATION
 I have answered all questions to the best of my knowledge.
 I have read and understood the information leaflet provided by the University in relation to my
work.
 I will report any symptoms of possible allergic reactions to substances encountered in my work.
Signature ............................................................................. Date ................................................
SECTION D: FOR OCCUPATIONAL HEALTH SERVICE USE
Test Results
Measurement
FVC
FEV1
FEV1/FVC
Predicted
Actual
Comments
Outcomes and Actions
Refer to OH Physician
Considerations/Recommendations
OH Database
Yes
☐
☐
☐
No
☐
☐
☐
Date of next Health Surveillance Review
Annual .......................................................................
Other .......................................................................
Appointment given
Yes ☐ No ☐
Nurse Signature ……………………………………………………… ………… Date …………………
Processed in accordance with the Data Protection Act 1998
i/admin/Safety Services/OH-Services/Templates/Respiratory Follow-up Health Assessment (online version)