Prospective Employer: Prospective Role:
Firstname: Surname: Date of Birth: Home Address: Email: Contact Tel: GP Name: GP Address: GP Phone:
1. Do you smoke? If yes, please quantify your daily intake? YesNo
2. Do you drink alcohol? If yes what is your weekly consumption in units (1 glass of wine=1 unit, Pint of Beer=2 units, Spirit=1.5units) YesNo
3. Are you currently using, or have you used in the last 5 years, any drugs of abuse (cocaine; opiates e.g heroin/methadone; marijuana; ecstasy; amphetamines)? YesNo
4. Have you ever been denied a job on health and safety grounds? YesNo
5. Have you ever been medically retired from a job, or had to leave a job on grounds of ill health? Please give details if so. YesNo
6. Are you under the care of a specialist consultant or hospital clinic for the management of any health condition? Please give details if so. YesNo
7. Are you on the waiting list for hospital investigations or treatment? Please give details if so. YesNo
8. Are you currently taking any medication? If so please list the name and the indication for taking it. YesNo
9. Within the last 2 years have you been absent for longer than 10 continuous days due to illness/injury? Please give details if so. YesNo
Please answer yes if you are currently suffering with, or have any past history of the following conditions. If you answer yes to any of the questions below please provide further details on the nature of your condition.
1. Do you have any endocrine/glandular problems (diabetes/thyroid etc)? YesNo
2. Any neurological disorders (fits, blackouts, migraine, epilepsy, stroke/TIA, MS)? YesNo
3. Have you ever suffered from a fatigue syndrome (post-viral fatigue, ME, fibromylgia, burnout etc)? YesNo
4. Any skin problems (moles, eczema, psoriasis, dermatitis)? YesNo
5. Any forms of cancer or tumours (benign or malignant)? YesNo
6. Have you ever had an operation? YesNo
7. Any work related upper limb disorder, repetitive strain injury or tendonitis? YesNo
8. Any ear disorders, perforations, discharge, middle ear infection or surgery for an ear disorder? YesNo
9. Will you require any adjustments or assistance to be able to do the proposed job (e.g in circumstances where you may have a mobility issue, musculoskeletal disorder or learning disability)? YesNo
10. Any psychiatric, mental health issues or psychological problems including anxiety, depression, panic attacks, post-traumatic stress, eating disorders, schizophrenia, OCD etc? YesNo
11. Any back, neck, shoulder, knee or other joint problems; or arthritis, gout or other rheumatological disorder e.g back pain, disc prolapse, disc surgery or injections, soft tissue/muscular injury, work-related back or joint injury or any issues requiring physiotherapy? YesNo
12. Have you ever experienced any difficulties wearing safety footwear? YesNo
13. Any heart or circulation problems e.g heart attack, angina, high blood pressure, heart murmur, problems with leg swelling/varicose veins or circulation in the legs? YesNo
Please confirm that you consent to the Westport Medical Clinic retaining this data in your employee medical file: Yes
