Download Confidential Health Declaration

SALFORD ROYAL NHS FOUNDATION TRUST
Occupational Health Service Confidential Health Declaration
Delay in returning this questionnaire or omission of complete details as requested may affect your
commencement date.
PLEASE COMPLETE IN BLOCK CAPITALS
Surname:
Forename
Previous
name (if any)
Mr/Mrs/Miss/Ms/
Dr/Prof/Other
Place of Birth
Male/ Female
Date of Birth
National Insurance No
Present
Address
including
Postcode:
Contact
Details:
Telephone:
Mobile:
Name &
Address of
GP (Family
Doctor)
GP Contact
Number
Please ensure you are registered with a local GP
Post Title:
Department:
Job Reference No:
Is this in addition to your current occupation?
YES/NO
Do you work for Salford Royal Hospitals NHS Trust at present?
YES/NO
Have you previously worked for Salford Royal Hospitals NHS Trust YES/NO
If YES please supply dates
from .../…/… to ..../..../…
Have you been examined for NHS employment before?
YES/NO
If YES please supply details of where and when.
The contents of this form will remain confidential to the Occupational Health Service and will not be disclosed to
anyone without your written consent. This information will be used to assess your safety and capability in the
proposed post. It will help the Occupational Health Service to advise managers on your fitness and on
accommodating your health and welfare needs whilst at Salford Royal NHS Foundation Trust.
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PREVIOUS OCCUPATIONS DURING THE LAST 10 YEARS
To enable us to organise your occupational health care, please list all jobs you have had (when, where, how
long you did them for) together with information about any hazards e.g. dust, chemicals, noise etc. to which you
were exposed. If necessary please continue on the continuation section of this screening questionnaire.
From – To
Employer
Nature of Employment
PLEASE  either YES or NO as Appropriate:
YES
Have you seen a doctor in the last year for any
reason?
Are you waiting for or are you having any
treatment or investigations?
Have you ever had a medical restriction on your driving
licence?
Have you ever retired from work due to ill
health?
Are you taking any injections, pills, tablets or medicines
from a doctor?
Have you had any absences from work (or school) due to ill
health during the past 2 years? (please state total days off,
on how many occasions and reasons?
Do you have or think you might have any allergies?
e.g. drug allergy, latex allergy, food, glutaraldehyde etc.
Are you pregnant?
A positive answer will not be used to discriminate against candidates but used to
advise you under the EC Directive on Pregnant Workers (92/85/EEC) regarding
physical, chemical or biological hazards in the workplace.
Do you have any difficulties understanding writing or speech?
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NO
Hazards Exposed to
(if any)
DETAILS
Do you have, or have you ever had any of the following? PLEASE  YES or NO as appropriate: For those marked yes
please give further details. Please use the continuation page if more space is needed.
No MEDICAL HISTORY
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Heart condition or Circulatory disease e.g. High blood
pressure, Angina, Stroke, Heart attack.
2a
2b
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Chest condition, e.g. Asthma, Bronchitis, TB (Tuberculosis)
or Pneumonia
In the last 12 months, have you had a cough for more than 3
weeks, coughed up blood or had any unexplained loss of
weight or fever?
Stomach or bowel condition e.g. Irritable bowel, Colitis,
Ulcers
Blood disorders or Liver Disease e.g. Anaemia, Jaundice,
Hepatitis, Blood Clotting disorders
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Disorders of the Bladder or Kidneys e.g. Incontinence,
Nephritis
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Diabetes, Thyroid or other Gland condition
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Musculoskeletal condition e.g. Back, Neck or Disc condition,
Sciatica, Joint problem, Arthritis or Injury, Hand/Foot condition
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Nervous System condition e.g. Epilepsy, Blackouts, Fits,
Fainting, Dizziness
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Severe, frequent or prolonged Headaches, e.g. Migraine,
Sinusitis
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Mental Health Condition even if mild e.g Depression, Anxiety,
Eating Disorders, Schizophrenia, Stress
Drug/Alcohol misuse or dependence (Support will be made
available to you if you acknowledge a need for help)
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Skin condition e.g. Eczema, Dermatitis, Infections, Skin
rashes
Ear Condition e.g. Hearing impairment, Infections, or have
you ever needed a hearing test?
Eye Condition e.g. Impaired vision, Colour Blindness or do
you wear Glasses or Contact Lenses?
Gynaecological condition e.g. endometriosis, menorrhagia,
fibroids?
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Any illness/condition which may have been caused or made
worse by work?
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Do you have any other medical or surgical condition?
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Have you undergone any surgical procedures?
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Do you have any illnesses of your immune system
Which may leave you vulnerable to infection.
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YES
NO
Date, Detail & Duration
INFECTIOUS DISEASES/ IMMUNISATION RECORD
NB: It may be necessary to request copies of some results and repeat some tests to comply with
Department of Health guidance.
Immunisation/Test
Date/Year of
Immunisation/Illness
Where ?
GP, Occ Health
etc.
Relevant Tests (if applicable)
TUBERCULOSIS SKIN TEST
Heaf,/ Tine,/ Mantoux
B.C.G. (TB Vaccine)
Result indicated immunity
Yes/No/Not known
Scar present: - Yes/No
RUBELLA
(German Measles)
M.M.R.
(Measles, Mumps, Rubella)
Antibody Test - Yes/No
Immune: Yes/ No / Not known
CHICKEN POX
State that you have had the
disease only if certain
Antibody Test: - Yes/No
Immune: Yes/ No/ Not known
HEPATITIS B
Antibody Test: - Y/N
Date of Last Test …./…./….
Immune : Yes/No/ Not known
Carrier State Positive:
Yes/No/Not known
HEPATITIS C
Antibody Test
Yes/No
Date of last test ……/ ……. /……
HIV
Antibody result
+ve / -ve
Antibody Test
Yes/No
Date of last test ……/ ……. /……
Antibody result
+ve / -ve
MEASLES
MUMPS
POLIO
TETANUS
TRIPLE VACCINATION
(Diphtheria, Whooping cough and
Tetanus combined, usually given in
Childhood)
HEPATITIS A
Antibody Test: - Y/N
Immune: Yes/ No / Not known
TYPHOID
MENINGITIS
OTHER VACCINATIONS
CHEST X-RAY
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Continuation information:
Declaration
YOU ARE ASKED TO READ THE DECLARATIONS BELOW, AND TO SIGN AND DATE THE FORM WHEN
YOU HAVE UNDERSTOOD THEM.
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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 employment.
I consent to a medical examination if necessary and that relevant details and results of any tests may be
sent to my General Practitioner.
I consent to the Occupational Health Service obtaining details of any previous health screening carried out
by other occupational health departments, which will be discussed with me if the need arises.
I understand that if a report is required from my GP or any of my treating doctors I will be informed of this
request. Any such report will be obtained in accordance with the Access to Medical Reports Act 1988 with
my separate written consent.
I understand that as a health care worker I have an overriding ethical as well as legal duty to protect the
health and safety of my patients. I therefore understand that if I have or believe I may have a serious
communicable disease (e.g. HIV, Hepatitis B or C) that I should declare this in confidence to the
Occupational Health Nurse/Doctor.
Signed: …………………………………………………. Date: …………………………………………………….
Thank you for completing this questionnaire
If you have queries regarding this questionnaire, please contact the Occupational Health Service at the following
address:
Occupational Health Service
Salford Royal NHS Foundation Trust
Hope Hospital
Stott Lane
Salford
M6 8WH
Tel:
0161 206 5768 Fax: 0161 206 5767
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