Gipping Hand Arm Vibration Questionnaire | Gipping Occupational Health

Personal Details

Name

Prefix First Names Surname

Home Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email Address

Home Phone Number

Work Phone Number

Mobile Number

Date of Birth

Doctor's Name

Doctor's Address

Street Address City County / State / Region ZIP / Postal Code Country

Doctor's Contact Number

Employer

Role

Manager's Name

Employer Address

Street Address City County / State / Region ZIP / Postal Code Country

Vibration Exposure

Are you Left or Right handed

Left Handed
Right Handed

Where do you notice the vibration the most when you are using the vibration tools?

Which of the main elements of your current job involve vibration and how much time a day is spent on vibration work?

When did you join the company?

List your main jobs and departments in order whilst working for your current company?

Are you aware of any vibration control monitoring for the tools?

Have you had health surveillance previously with your current company?

Do you currently use any Personal protective equipment (PPE) whilst operating vibration tools?

What jobs have you had previously, outside of your current company, involving vibration?

Please provide details of the tools used, company and how long you worked for that company.

Were you aware of any vibration control monitoring for the tools?

Have you had health surveillance for exposure to vibration with previous companies?

Did you previously use any Personal protective equipment (PPE) whilst operating vibration tools?

Have you had any exposure to chemicals or neurotoxic agents?

Yes
No

Please provide details

Have you had any claims with previous employers for hand arm vibration or whole body vibration issues?

Yes
No

Please provide details

Social History/ Leisure Pursuits

Do you ride a motorbike?

Yes
No

Do you use power tools such as drills, sanders, nail gun etc. at home?

Yes
No

Do you use gardening tools such as a lawn mower or any other machines outside of your regular job?

Yes
No

Do you have a secondary job which involves any of the above or work similar to your current role?

Yes
No

Do you smoke?

Yes
No

Have you ever smoked?

Yes
No

Do you drink alcohol?

Yes
No

Average units per week

If you have answered yes to any of the above answers please give details below:

Medical and Family History

Do any other members of your family suffer from circulatory problems such as Raynaud’s Disease or similar problems? Brothers, sisters and parents only.

Yes
No

Please provide details

Have you ever had a hand / arm / hand / neck / back / chest injury or operation?

Yes
No

What and when?

Are there any residual symptoms or deformities?

Yes
No

Please provide more details

Are you experiencing any other problems with muscles or joints of your hands or arms such as pain/weakness/swelling/ stiffness?

Yes
No

Please provide more details

Do you have any difficulty with fine movements of your fingers?

Yes
No

Do any of these symptoms affect your work or leisure activities?

Yes
No

Have you ever suffered with: Polio, Hypertension, Carpel Tunnel Syndrome, Angina / Myocardial Infarction, Multiple sclerosis, Cerebrovascular Accident (Stroke) Skin disease

Yes
No

Please provide details

Are you taking any prescribed or non-prescribed medication for any condition?

Yes
No

Please provide details

Declaration and Authority to Release Information

The Health and Safety at Work Act 1974, requires employers to ensure, so far as is reasonably practicable, your health, safety and welfare while at work. To help us to help you and your employer, we are asking you to complete this form before attending for your health assessment.
At the health assessment, you will be asked further questions about your health and your work. Medical information is held in Confidence by the Occupational Health Service and is not passed on without your specific written consent.
The use of personal sensitive information is regulated in law by the General Data Protection Regulations (GDPR) and covered by the ethical requirements of the General Medical Council/Nursing & Midwifery Council. A copy of our Privacy Notice which relates to how we handle your personal sensitive information is available on request.
Any information requested from a treating Doctor is in accordance with the Access to Medical Reports Act 1988 and the General Data Protection Regulations.
Any information supplied to your employer is about your ability to work safely and without detriment to your health.

Declaration

I declare that each and every answer above is true to the best of my knowledge and belief and I consent to a physical assessment

Statement of Authorisation

I hereby authorise the examining Occupational Health Advisor to submit a report to my employer regarding my fitness for the role

Personal Details

Vibration Exposure

Social History/ Leisure Pursuits

Medical and Family History

Declaration and Authority to Release Information

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