Download Occupational Health Questionnaire

Occupational Health Medical Questionnaire for Agency Workers
Personal Information
Title:
Home Telephone:
Home Address:
Email Address:
First Name:
Mobile:
Surname:
DOB:
Work Telephone:
GP/Health Professional Address:
National Insurance No:
HCPC Pin:
Asprey Medical Services Limited, Suite 14, Colchester Business Centre, 1 George Williams Way, Colchester, Essex, CO1 2JS Telephone Number:
01206 586050, Fax Number: 01206 581500. Registered in England and Wales no: 08452300
Health Information
Please answer carefully the questions below. If your answer to any of these questions is ‘YES’ please provide
further details. Incomplete forms and/or failure to provide details will result in a delay in being able to put you
forward for assignments within the NHS
(Please delete as appropriate)
Do you have any problems that may have been caused by work?
YES / NO
Do you have any health problems that you think may affect your performance or safety at work?
YES / NO
Do you have any problems with hearing?
YES / NO
Do you have any problems with your eyesight (not connected with spectacles/contact lenses)?
YES / NO
Do you suffer from any chest problems – e.g.: Asthma, Bronchitis, TB?
YES / NO
Have you had any skin problems – e.g.: Eczema, Psoriasis, Rashes, Recurrent skin infections?
YES / NO
Do you have or have you ever suffered from any allergic reactions or allergies? (e.g.: latex)?
YES / NO
Have you ever suffered from any blackouts, faints or fits?
YES / NO
Have you ever had any mental health problems (including anxiety, depression, nervous breakdowns, stress, selfharm, eating disorders and addictions)?
YES / NO
Have you or do you have persistent backache, sciatica, disc, or other back problems?
YES / NO
Do you suffer from any health problems that cause you difficulty with?
- Sitting
YES / NO
- Standing
YES / NO
- Moving around
YES / NO
- Bending, lifting or carrying
YES / NO
- Working with a computer
YES / NO
Are you taking any medication (except contraception)?
YES / NO
Are you receiving any other form of treatment at the moment?
YES / NO
Have you consulted a Doctor, Counsellor or alternative therapist in the last two years?
YES / NO
Are you waiting for any investigations, treatments or admission to a hospital?
YES / NO
Have you been absent from work/study for more than 2 consecutive weeks due to illness in the last two years?
(If yes, please give details of each occurrence below)
YES / NO
Do you consider yourself to have a disability?
YES / NO
(If yes, please give details of any modification needs at your place of work)
Do you have any other health problems/medical conditions not covered in the above questions?
YES / NO
(If yes, please give details below)
Have you ever been retired from work on grounds of ill health?
YES / NO
Have you ever had any infectious disease or blood borne virus?
YES / NO
If you have answered YES to any of the above, please use this space to provide further details:
Asprey Medical Services Limited, Suite 14, Colchester Business Centre, 1 George Williams Way, Colchester, Essex, CO1 2JS Telephone Number:
01206 586050, Fax Number: 01206 581500. Registered in England and Wales no: 08452300
Immunisation& Vaccination Details
Please complete this form indicating whether you have or have not had these immunisations/blood tests, enclosing
copies of the relevant documentary evidence where requested. Please ensure that any copies of blood tests,
immunisations and vaccinations reports clearly show the source of the report, who it refers to and is signed AND
stamped by your General Practitioner/Practice Nurse or an Occupational health Department.
1 Varicella (Chicken Pox)
YES
NO
Date
YES
NO
Document
Attached
1.1 Have you ever had Chicken Pox or Shingles? If ‘YES’, confirm approximate
date, add your signature, and proceed to the next section 2 (MMR)
Please sign here if you have answered yes to self-certify exposure to Chicken
pox/Shingles
1.2 If the answer to 1.1 is ‘NO’ or you are unsure, have you undertaken a blood
test to confirm presence of the VZ antibody? If ‘YES’ please attach a copy of the
report.
1.3 If blood test showed that the VZ antibody was NOT present, or equivocal,
have you undertaken a varicella vaccination? If ‘YES’ please attach the
certificate of vaccination or verified immunisation history report.
2 Measles, Mumps & Rubella (German Measles)
YES
NO
Document
Attached
NO
Document
Attached
2.1 Have you had the 2-dose MMR vaccination or single vaccinations for Mumps,
Measles, or Rubella? If ‘YES’ please attach certificate of vaccination and proceed
to next section 3(Hepatitis B). If ‘NO’, or you do not have vaccination record,
please see 2.2 & 2.3 below.
2.2 Have you undertaken a blood test to confirm immunity to Rubella? If ‘YES’,
please attach a copy of the report.
2.3 Have you undertaken a blood test to confirm immunity to Measles? If ‘YES’
please attach a copy of the report.
3 Hepatitis B
Please provide the following information to ascertain your Hep B Immunity:
YES
3.1 Have you received part or all of the three dose Hep B vaccination or part
of the 4 –dose accelerated Hep B vaccination course? If ‘YES’ please attach
certificate of vaccination or verified immunisation report.
3.2 Have you received the 5-year booster Hep B vaccination? If ‘YES’ please
attach certificate of vaccination or verified immunisation history
3.3 have you undertaken a blood test within the UK to check your response to
immunisation? If ’YES’ please attach a copy of the report (this must be an
IDENTIFIED VALIDATED SAMPLE – see below)
Asprey Medical Services Limited, Suite 14, Colchester Business Centre, 1 George Williams Way, Colchester, Essex, CO1 2JS Telephone Number:
01206 586050, Fax Number: 01206 581500. Registered in England and Wales no: 08452300
3.4 If you have answered ‘NO’ to any of the above 3 questions, have you
recently undertaken within the UK a Hep B surface antigen test? If ‘YES’
please attach a copy of the report
Identified Validated Samples
An Identified validated sample is defined according to the following criteria:
The Candidate should show proof of identity with a photograph when the sample is taken (e.g. Passport or photo
driving licence)
Samples should be delivered to the laboratory in the usual manner, not transported by the candidate
The Lab report should be stamped IVS or give proof that the IVS protocol has been carried out.
All the Pathology reports from NHS bodies after January 2003 are accepted as Identified Validated Samples. If your Hep B report
comes from a non NHS body, please provide written confirmation that the IVS system was used.
4 Tuberculosis Vaccination
Please provide the following information to ascertain your immunity to TB
YES
NO
Document
Attached
4.1 Have you received a BCG tuberculosis vaccination? If ‘YES’ please attach
evidence of vaccination (if available) and proceed to 4.2. If ‘NO’ proceed to 4.3.
4.2 If you have received the BCG vaccination, have you had your BCG scar
verified by a General Practitioner or Occupational Health practitioner, if ‘YES’
please attach a written verification, signed by the relevant practitioner, then
proceed to section 5. (TB Status)
4.3 If you do not have a visible BCG scar (or have not been immunised for TB),
have you undertaken a Mantoux/Heaf test within the last 2 years? If ‘YES’
please attach a copy of the report.
5 Tuberculosis Vaccination
YES
NO
YES
NO
Have you ever been diagnosed with TB or been in recent contact with open TB?
Have you ever had any unexplained chest illness?
Have you ever had an abnormal chest x-ray?
Have you recently had the mucus you cough up tested for TB?
If yes to above were you told that it was positive?
Have you ever been told that you have Infectious TB? If yes , provide dates below
Have you ever been treated with medication for infectious TB? If ’YES’, provide dates below
Do you live with or have you been in close contact with someone who was recently
diagnosed with TB? (e.g. roommate, close friend, relative)
Current TB Symptoms
Do you have a cough that has lasted for longer than three weeks?
Do you cough up blood or mucus?
Have you lost your appetite? Aren’t Hungry?
Have you lost a lot of weight (more than 10 lbs) in the last 2 months, without trying to?
Do you have night sweats (need to change the sheets or your clothes because they are wet?
Asprey Medical Services Limited, Suite 14, Colchester Business Centre, 1 George Williams Way, Colchester, Essex, CO1 2JS Telephone Number:
01206 586050, Fax Number: 01206 581500. Registered in England and Wales no: 08452300
Please list any details here:
Recent Overseas Travel
YES
In the last three years, have you spent any time living or working outside of the UK?
(excluding the European Union, USA, Canada, Australia, New Zealand). If ‘YES’ please
complete below.
Country Visited
Date
NO
Duration of Stay
Asprey Medical Services Limited, Suite 14, Colchester Business Centre, 1 George Williams Way, Colchester, Essex, CO1 2JS Telephone Number:
01206 586050, Fax Number: 01206 581500. Registered in England and Wales no: 08452300
Access to Medical records – Consent Form
Our occupational Heal Providers (Colchester Hospital University NHS Foundation Trust) may need to obtain further
information from your doctor/specialist to complete your assessment. To do this your consent is required. Under the
Access to Medical Reports Act 1988 you have the right to see your doctor’s report before it is sent to the
Occupational Health Advisors. You should give your consent and indicate whether you wish to see the report, if
requested, by signing below.
Your Rights
1. The OH advisor will let you know in writing if she/he requests a medical report. You can ask to see the report
before the doctor returns it. If this is the case, the doctor will keep the report for 21 days so that you can
arrange to see it. It will not be automatically sent to you. If you have not made arrangements to see your
report within this time, the doctor will send it to the OH advisor.
2. Your doctor should be willing to discuss the report with you. If you think the information provided is
inaccurate or misleading, you can ask the doctor to change it although they are not obliged to do so. If you
cannot reach an agreement you have the right to add a statement of your own on to the report, or withdraw
your consent.
3. Your doctor does not have to show you any part of the report if she/he thinks it may include information
that may seriously harm your physical or mental health or where the identity of a person who has supplied
information about you in confidence could be revealed. He/she should tell you this if it is the case.
4. You can arrange to see the report up to 6 months after it has been supplied.
5. Please note that when Occupational Health requests a GP report, some or all of this questionnaire may be
included.
Please complete and sign:
I consent to my doctor providing information about my health to the Occupational Health Advisors (please tick only
one box)
I do wish to see the report, if request
I do not wish to see the report if requested
Your General Practitioner Details
GP Name & Address:
GP Telephone Number:
Your Details
First Name:
Surname:
DOB:
Signature:
Asprey Medical Services Limited, Suite 14, Colchester Business Centre, 1 George Williams Way, Colchester, Essex, CO1 2JS Telephone Number:
01206 586050, Fax Number: 01206 581500. Registered in England and Wales no: 08452300
Declaration (All applicants should complete and sign the declaration below)
I have read the information for applicants and have answered all the questions to the best of my knowledge. I
understand that, should I conceal relevant information or deliberately provide misleading information about my
health, any offer of an assignment from Asprey Medical that has been made may be withdrawn, of, If I am already
on assignment for Asprey Medical my assignment may be withdrawn.
If I accept an assignment to work through Asprey Medical Services within an NHS hospital in England or Wales, I
understand that my fitness to work status and Immunisation history/reports may be released to NHS PASA’s
(Purchasing Supplies Agency) auditors to assess compliance with the National Framework Agreement for the
supply of Allied Health Professional and Health Science Services to the NHS (CM/AST/08/4966)
Signature:
Date:
Asprey Medical Services Limited, Suite 14, Colchester Business Centre, 1 George Williams Way, Colchester, Essex, CO1 2JS Telephone Number:
01206 586050, Fax Number: 01206 581500. Registered in England and Wales no: 08452300