Pre-Employment Health Questionnaire | Carrig Occupational Health

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Pre-Employment Health Questionnaire

Date of Completion * required

Company

Phone

Shift work *

Yes

No

Position Applied for

Date of Birth (PRINT)

Sex

First and Last Name

Email

Home Address

Family Doctor

Covid Screening

Do you have any symptoms or belive you have Covid 19 or influenza currently? *

Yes

No

Medical Consent

I confirm that I have been told about this assessment, what the reasons are, and that records will be kept, and I agree to take part in the examination. I confirm I understand the purpose of the assessment is to provide my employer with advice regarding my fitness for work and any advice will be expressed in terms of fitness to carry out my duties now and in the future.

Occupational History

Please give brief details on job titles, employers, dates of employment and hazard exposures. *Please note that hazards can include: Manual handling, Chemicals, Noise and Extreme temperatures

Social History

Smoking? *

Yes

No

Vaping? *

Yes

No

Do you drink alcohol? *

Yes

No

Do you exercise? *

Yes

No

If yes, how many per day? Have you ever smoked? When did you stop?

Did you ever vape? When did you start/stop?

How many units per week? (2 units of alcohol = glass of wine/pint of beer)

Type of exercise and frequencey?

Medical History

Current health

If you say yes to any question, please give more detail at the end of each section in the box provided

01.Are you currently under medical care? *

Yes

No

02.Have you had any operations? *

Yes

No

03.Have you been in hospital otherwise? *

Yes

No

04.Are you allergic to anything? (This can include medication but also chemicals/latex or hay fever type allergy) *

Yes

No

05.Are you taking any Medications? *

Yes

No

06.Are you receiving any treatment or waiting for any treatment or investigations at the moment? *

Yes

No

If you answered 'Yes' to any of the above, please add details and dates.

Do you suffer from or have you ever had?

Current Health

01.Have you lost time from work or education due to sickness in the last 2 years? *

Yes

No

02.A fear of confined spaces (claustrophobia) *

Yes

No

03.A fear of heights or open spaces (agoraphobia) *

Yes

No

04.Fainting/ Dizziness/ Fits /Blackouts/ Epilepsy *

Yes

No

05.Recurrent headaches or Migraine *

Yes

No

06.Mental illness or nervous trouble (including anxiety or depression or any stress related illness) *

Yes

No

07.Eye disorder or disturbance of vision *

Yes

No

10.Tuberculosis *

Yes

No

13.Any heart disease or disorder? (Including pacemaker) *

Yes

No

16.Any skin problem such as Dermatitis, Psoriasis, eczema, or skin allergy (including chemical or latex allergy) *

Yes

No

19.Lower limb injury or trouble *

Yes

No

22.Do you believe you have any health issues that may need work accommodation? *

Yes

No

08.Any chest complaint(s)? *

Yes

No

11.High Blood Pressure *

Yes

No

14.Diabetes *

Yes

No

17.Back or neck trouble e.g., muscular problems, whiplash, disc prolapse *

Yes

No

20.Arthritis, joint problems, gout? *

Yes

No

23.Any other significant medical condition? *

Yes

No

09.Respiratory Illness *

Yes

No

12.Any Gastrointestinal problems (can include IBS, Crohn’s, colitis etc.) *

Yes

No

15.Drug or alcohol misuse *

Yes

No

18.Upper limb injury or trouble (work related or otherwise)? *

Yes

No

21.Have you ever had pain or discomfort when bending or lifting? *

Yes

No

24.Ever played in a band or shoot guns? If so, what hearing protection was/is used? *

Yes

No

25.Ear or hearing trouble, ear infections, or deafness or family deafness (in younger years) *

Yes

No

26.Did you ever work in a loud environment where you had to raise your voice to be heard? If yes, please specify employer and duration of employment *

Yes

No

If you answered 'Yes' to any of the above, please add details and dates.

I undertake to notify my employer/ regulatory bodies (if applicable) immediately of any subsequent change to my state of health or other concerns that may affect my fitness to work.

I declare that the information provided is truthful and that I have disclosed all relevant information regarding my health and fitness to work. I acknowledge that failure to disclose information, or submission by me of information that is subsequently found to be false may render my employment Null and Void

I give permission for my pre-employment assessment record to be shared with onsite Occupational Health department for the purpose of ongoing on-site occupational health support and monitoring in line with HSA compliance and will be shared by secure file share.

I declare that the information provided is truthful and that I have disclosed all relevant information regarding my health and fitness to work. I acknowledge that failure to disclose information, or submission by me of information that is subsequently found to be false may render my employment Null and Void

I acknowledge I must be 16 hours noise free before doing the hearing test to get an accurate reading. This means avoiding loud noise e.g. DIY or concerts without hearing protection 16 hours before doing the medical. If you are unsure if you have been exposed to loud noise, please make the nurse aware on the day of the medical.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

Contact

Carrig Occupational Health

Carrig Clinic, Zoe House, Hillside Rd Greystones, A63 WK40

Phone: 01 2875932

Email: admin@carrigclinic.ie

Opening Hours

Monday-Friday: 09.00-17.00

Weekends & Bank Holidays: Closed

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