PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2015
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 Declaration to 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: www.cardiffmet.ac.uk/ohq 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:
Tel (Home):
GP Details: Dr
Address:
Mobile:
Tel No:
E-mail:
Postcode:
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 delete as appropriate
Are you currently exposed to latex?
If yes give details, e.g. wear gloves daily.
Yes / No
Have you been diagnosed with a latex allergy?
If yes please give details:
Yes / No
Has any employment ever been terminated on health grounds?
If Yes please give details:
Yes / No
Do you have any disability you wish to disclose in order that
assistance or help with modifications to your workplace can be provided?
If Yes please give details:
Yes / No
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
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
YES
NO
DETAILS (dates, treatments, medications)
CONDITION
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?
YES
NO
DETAILS (dates, treatments, medications)
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)
Have you had
Yes
Yes
No
No
Never
Tested
Date(s)
Management/Treatment
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
Diptheria/Tetanus/Polio
Inoculations
Meningitis C Inoculation
Any other inoculations,
please state
Immune / Non-immune (lab report– enclose copy if
possible)
PART E – Applicant Declaration to 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
healthcarestudents@fulcrumreporting.co.uk 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:……………………………