Respiratory Baseline Assessment
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Occupational Health Service BASELINE RESPIRATORY ASSESSMENT Private and Confidential 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 .......................................................... EXPOSURES Type of respiratory sensitiser? ............................................................................................................ How are you exposed to this? .............................................................................................................. ............................................................................................................................................................ Level of exposure: Hours per day ........................ Days per week . ............. Weeks per month ............ Other ................................................................................................................... HEALTH SURVEILLANCE Do you feel well today? ........................................................................................ Yes ☐ No ☐ If no give details ............................................................................................................................... Do you have 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. Eczema, dermatitis or allergic skin rashes, especially if scratched ................... Yes ☐ No ☐ If you have ticked YES to any of the above, please give details ….. ............................................................................................................................................... 8. Do you suffer from allergies .............................................................................. Yes ☐ No ☐ 9. Do you smoke ................................................................................................. Yes ☐ No ☐ If you have ticked YES to any of the above, please give further details ..................................................................................................................................................... 10. Do you have any hobbies? Please list ....................................................................................... PAST MEDICAL HISTORY Have you ever had: Injury or operation affecting your chest ……………………………………… Yes ☐ No ☐ Heart surgery ........................................................................................... Yes ☐ No ☐ Pneumonia ................................................................................................ Yes ☐ No ☐ Other chest trouble .................................................................................... Yes ☐ No ☐ If you have ticked YES to any of the above, please give details ................................................ ….. ............................................................................................................................................. Have you had time off work due to these symptoms? ………………………………..Yes ☐ No ☐ If yes give details ..................................................................................................................... Have you worked with any hazardous substances in any previous employment? Yes ☐ No ☐ If you have ticked YES to any of the above, please give details ................................................ ….. ............................................................................................................................................. 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 Yes No Refer to OH Physician ☐ ☐ Considerations/Recommendations ☐ ☐ OH Database ☐ ☐ Date of next Health Surveillance Review Annual ....................................................................... 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)
