Gipping Health Questionnaire | Gipping Occupational Health

Name*
First Name(s) Surname
Home Address*
Email Address*
Primary Phone Number*
Mobile Phone Number
Work Phone Number
Date of Birth*
DD slash MM slash YYYY
Doctors Name*
Doctors Address*
Doctors Contact Number*
New/Current Employment/Worker Details
If you are completing this form as part of a pre-employment process could you complete this section with your new company / employer details
Company Name*
Subsidiary Group
Job title/role*
Night worker*
- Yes
- No
Start date*
DD slash MM slash YYYY
Location*
Line Manager*
Work History
(at least 5 years, most recent first)
Employment / Company Details*
Please include employers / company name, your job title with the company and how long you worked there.
Health History
Have you ever had any of the following in the past?
Conditions of the lungs? Asthma? Bronchitis? Pleurisy? Tuberculosis? Other chest complaints? Coughing up blood? Shortness of breath? Any other conditions?*
- Yes
- No
Please provide details and dates
Conditions of the heart? Heart Attacks? Angina? High/Low blood pressure?*
- Yes
- No
Please provide details and dates
Clots in the legs or lungs Excessive bleeding or bruising?*
- Yes
- No
Please provide details and dates
Nervous system disorder? Blackouts? Epilepsy? Muscular weakness? Paralysis? Head injury? Concussion?*
- Yes
- No
Please provide details and dates
Migraine or persistent headaches?*
- Yes
- No
Please provide details and dates
Conditions of the digestive system? Irritable bowel syndrome? Liver complaints/jaundice? Colitis? Gastric/duodenal ulcer? Any other conditions?*
- Yes
- No
Please provide details and dates
Hernia?*
- Yes
- No
Please provide details and dates
Conditions of the kidney or bladder? Urinary infection? Kidney stones?*
- Yes
- No
Please provide details and dates
Conditions or injuries of the bones, joints and limbs? Broken bones or fractures? Arthritis? Rheumatism? Sciatica? Shoulder problems? Upper limb disorder? Tennis elbow? Repetitive Strain problems? Any other condition?*
- Yes
- No
Please provide details and dates
Back problems? Neck or spinal problems? Prolonged back, neck or shoulder pain?*
- Yes
- No
Please provide details and dates
Rheumatic fever?*
- Yes
- No
Please provide details and dates
Allergies? (Including allergies to drugs, animals, bee stings and pollens).*
- Yes
- No
Please provide details and dates
Skin conditions? Eczema? Dermatitis? Psoriasis? Recent skin Infection? Skin cancer?*
- Yes
- No
Please provide details and dates
Gland trouble? Thyroid overactive/under active?*
- Yes
- No
Please provide details and dates
Diabetes?*
- Yes
- No
Please provide details and dates
Eye Conditions? Restricted vision? Glaucoma? Iritis? Any other condition?*
- Yes
- No
Do you wear glasses/contact lenses?*
- Yes
- No
Please provide details and dates
Ear conditions? Restricted hearing? Tinnitus? Ear infections?*
- Yes
- No
Do you wear hearing aids?
- Yes
- No
Please provide details and dates
Cancer or other tumors?*
- Yes
- No
Please provide details and dates
Any history of tropical or infectious diseases? Eg Malaria, TB, Hepatitis?*
- Yes
- No
Please provide details and dates
Have you travelled abroad in the past 6 months?*
- Yes
- No
Please provide details and dates
Mental illness and/or stress related problems? Nervous breakdown? Mental fatigue? Anxiety? Depression? Panic attacks? Significant sleep disturbance? Stress related problems? Eating disorders? Self harm? Any other conditions?*
- Yes
- No
Please provide details and dates
Alcohol or drug problems? Problems related to alcohol or drug usage or dependency?*
- Yes
- No
Please provide details and dates
Are you receiving medical treatment at the present time?*
- Yes
- No
Please provide details and dates
Do you take regular medication?*
- Yes
- No
Please provide details and dates
Have you consulted your GP in the last 12 months?*
- Yes
- No
Please provide details and dates
Have you visited a therapist eg physiotherapist, osteopath, chiropractor etc. in the last year?*
- Yes
- No
Please provide details and dates
Do you expect to consult a doctor or expect to receive any treatment in the near future?*
- Yes
- No
Please provide details and dates
Have you spent any time in hospital other than already stated?*
- Yes
- No
Please provide details and dates
Have you ever had an X-ray, CT scan, Ultrasound scan, MRI scan?*
- Yes
- No
Please provide details and dates
Is there any history of serious illness or disease in your family?*
- Yes
- No
Please provide details and dates
Work Related Health History
Been absent from work or full time study due to ill health during the last 2 years (including illness such as colds etc)?*
- Yes
- No
Please provide details including reasons, days off and dates
Left or been denied a job on health grounds?*
- Yes
- No
Please provide details and dates
Been refused life/ disability insurance or military service for medical reasons?*
- Yes
- No
Please provide details and dates
Been denied a driving license on health grounds?*
- Yes
- No
Please provide details and dates
Had any disease or injury arising out of your work eg deafness, backache, dermatitis, asthma, vibration white finger or any other work related health conditions?*
- Yes
- No
Please provide details and dates
Worked in a dusty environment?*
- Yes
- No
Please provide details and dates
Worked in a noisy environment?*
- Yes
- No
Was hearing protection used during this time?
- Yes
- No
Please provide details and dates
Worked with chemicals?*
- Yes
- No
Did you suffer or experience any health problems associated with these chemicals?
- Yes
- No
Please provide details and dates
Worked with x-rays or other forms of radiation?*
- Yes
- No
Please provide details and dates
Worked with vibrating tools?*
- Yes
- No
Please provide details and dates
Have you ever been advised for medical reasons not to do night work, shift work, or any other kind of work?*
- Yes
- No
Please provide details and dates
Is there any reason why you cannot wear Personal Protective Equipment (PPE)?*
- Yes
- No
Please provide details and dates
Is there any other condition that may impact on your ability to safely perform the duties of your job?*
- Yes
- No
Please provide details and dates
Worked with asbestos, lead, biological substance or any respiratory or skin hazard?*
- Yes
- No
Please provide details and dates
Undergone health surveillance due to hazards in your job?*
- Yes
- No
Please provide details and dates
Social History
Do you drink alcohol?*
- Yes
- No
How many standard drinks in 1 week and what type of alcohol?
Have you ever felt you should cut down your drinking?*
- Yes
- No
Have people annoyed you by criticizing your drinking?*
- Yes
- No
Have you ever felt bad or guilty about your drinking?*
- Yes
- No
Do you currently smoke?*
- Yes
- No
How many cigarettes in 1 day?
How many years have you smoked?
Have you ever smoked?
- Yes
- No
How many cigarettes did you smoke in 1 day?
How long ago did you quit?
Do you use any recreational drugs?*
- Yes
- No
What types?
How often?
Do you engage in regular exercise?*
- Yes
- No
What types?
How often?
Do you bite your fingernails?*
- Yes
- No
Are you right or Left hand dominant?*
- Right
- Left
Physical Details
Do you have any difficulties with the following activities?
Running 50 metres*
- Yes
- No
Kneeling or crouching*
- Yes
- No
Climbing stairs or ladders*
- Yes
- No
Using hand tools*
- Yes
- No
Repetitive movement of hands or arms*
- Yes
- No
Working in extremes of temperature*
- Yes
- No
Walking on rough or uneven ground*
- Yes
- No
Standing or sitting for 2 hours or more*
- Yes
- No
Lifting or bending*
- Yes
- No
Gripping firmly with both hands*
- Yes
- No
Confined spaces or working at heights*
- Yes
- No
Shift work*
- Yes
- No
Concentrating on what you are doing*
- Yes
- No
Reading ordinary print*
- Yes
- No
Hearing a normal conversation*
- Yes
- No
Turning your head rapidly*
- Yes
- No
Understanding English including reading signs*
- Yes
- No
Vaccination History
Have you had the following Immunizations?
Tetanus*
- Yes
- No
- Unknown
When?
DD slash MM slash YYYY
Hepatitis A*
- Yes
- No
- Unknown
When?
DD slash MM slash YYYY
Hepatitis B*
- Yes
- No
- Unknown
When?
DD slash MM slash YYYY
Other vaccinations*
- Yes
- No
- Unknown
When?
DD slash MM slash YYYY
Details
Declaration and Authority to Release Information
• The Health and Safety at Work Act 1974, requires employers / Companies to ensure, so far as is reasonably practicable, your health, safety and welfare while at work. To help us to help you, we are asking you to complete this form. This form will be stored within your confidential Occupational Health Records.

• You may be contacted by the health assessment team and 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 / Company is about your ability to work safely and without detriment to your health. You may withdraw your consent to release personal sensitive information to your employer / Company at any point.
Declaration
- I declare that each and every answer above is true to the best of my knowledge and belief and I consent to being contacted first, as applicable prior to a physical assessment if required.
Statement of Authorisation
- I hereby authorise the Occupational Health Advisor to submit a report to my employer / company regarding my fitness for the role
Name*
First Name Surname

New/Current Employment/Worker Details

Work History

Health History

Work Related Health History

Social History

Physical Details

Vaccination History

Declaration and Authority to Release Information

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