Download Preliminary information for pre-employment health examination

Lääkärikeskus Aava Oy/Työterveyshuolto
Työhöntulotarkastuksen esitiedot, englanti
Versio 1.0
Sivu 1
PRELIMINARY INFORMATION FOR PRE-EMPLOYMENT HEALTH EXAMINATION
All given information is considered confidential
PERSONAL DATA
Last name
First names
Identity code
Address
Postal code
City
Home telephone / Mobile
E-mail address
Office telephone
Occupation/task
Marital status
Education
My family includes
adults and
child/children
Conscription completed in
Fitness class
Company name
Supervisor
Current job started in
Description of current job
Exposure present in current job (are they, e.g., psychological, chemical, physical, biological)?
Have you had sufficient training for your current work tasks?
Are you given enough time at work to complete your tasks?
PREVIOUS EMPLOYMENT
Employer
Profession
Dates
Employer
Profession
Dates
Employer
Profession
Dates
Employer
Profession
Dates
Employer
Profession
Dates
Employer
Profession
Dates
Employer
Profession
Dates
Did your previous work tasks contain exposures / stress factors (e.g., psychological, chemical,
physical, biological) relevant to your health?
Diagnosed occupational disease or work limitation
INFORMATION REGARDING YOUR STATE OF HEALTH
Current health? (On a scale of 0 to 10, Good = 10 Bad= 0)
Lääkärikeskus Aava Oy/Työterveyshuolto
Työhöntulotarkastuksen esitiedot, englanti
Versio 1.0
Sivu 2
How would you evaluate your well-being at the moment? (On a scale of 0 to 10, Good = 10, Bad= 0)
HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS OR ILNESSES?
FOR ALL QUESTIONS, SELECT ‘YES’ OR ‘NO’.
Yes
No
Yes
Neck/shoulder pains
Obesity
Lower back illness
Diabetes mellitus
Arm or leg pains
Epilepsy
Rheumatoid arthritis
Gallstones
Other musculoskeletal disorder
Disease of the liver or pancreas
Hypertension
Gastric ulcer
Chest pains
Disease of the large intestine
Cardiac insufficiency
Other disease in the digestive
organs
Other disease of the cardiovascular
system
Urinary tract infection
Prolonged rhinitis
Kidney disease
Recurring respiratory tract
infection
Women; ovarian infection
Asthma
Men; prostate disease
Pulmonary emphysema
Disease in the urinary and genital
organs
Other respiratory disease
Allergies
Mental disorder
Other eczema
Depression
Other skin disease
Sleep disorder
Benign tumour
Ear disease
Malignant tumour
Eye disease
Goitre or thyroid disease
Migraine
Celiac disease
Anaemia
Lactose intolerance
Other blood disease
Other metabolic disorder
Accident
Congenital defect
No
Other illness or disorder
Additional information
Medication
Allergies to medicines?
How many days of sick leave did you have last year?
Special diet
Eating habits
I eat regularly, approx. every 4 to 5 hours
Half or more of my plate contains vegetables,
fruits, or berries?
Lääkärikeskus Aava Oy/Työterveyshuolto
Työhöntulotarkastuksen esitiedot, englanti
Versio 1.0
Sivu 3
Yes
No
Yes
Exercise habits
time/week What exercise?
Smoking / snuff use
Yes
No
Alcohol use
I use alcohol, number of servings per time:
I do not use alcohol
Do you use other intoxicants?
Yes; what?
No
Vaccinations
Year
Tetanus-diphtheria
Polio
MPR
Other, what?
ONLY FOR WOMEN:
Child-births in
Are you pregnant?
Pap smear in
Mammogram in
DISEASES IN THE IMMEDIATE FAMILY:
Cardiovascular diseases
Hypertension
Diabetes mellitus
Asthma
Cancer
Mental disorders
Other diseases
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Previous health examination performed: in
No
I have smoked for
years
cigarettes/day
I quit smoking in
How often do you use alcohol?
times a day,
times a week,
times a months,
times a year
Teeth:
checked in
not checked
I use dentures
Vaccinations
Year
Hepatitis A +B
Hepatitis A
Hepatitis B
Yes, due date
No
No
No
No
No
No
No
No
who?
who?
who?
who?
who?
who?
who?
, where
I HEREBY CONFIRM THAT THE INFORMATION I HAVE PROVIDED IS TRUTHFUL:
Place and time
Signature of employee