Preston: 01995 602140 | Blackpool: 01253 978402 |
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NIGHT MEDICAL QUESTIONNAIRE


Price: £10.00

Tax: £2.00

Please complete all fields, sign and date before sending. Once complete please proceed to payment we accept the following: PayPal, Debit Cards, Credit Cards - please note for credit card payment only may take up to 3 working days and could delay in the issue of fitness certificates. All questionnaires are assessed by a qualified professional and if deemed fit a fitness certificate will be issued. If there are any medical issues identified on the form you will be contacted by telephone directly for further information. Fitness certificates will be sent WITHIN 1 WORKING DAY to the nominated person for your Company.



Personal Details (please complete all sections)

This form to be completed by Parent or Guardian if person is aged under 18 years old.

Gender


Ethnicity










Job Specification, Past & Present (Please tick all the appropriate boxes)

Requirements








Occupational Driving





Other

Please state any special requirements

Physical Demands






Work Environment Exposure












Previous Employment

Approximate Dates

Complete the following to the best of your knowledge. Ticking �Yes� does not mean you will not be fit for night/shift work but that a further assessment by an occupational health professional may be required


1 In general how would you rate your health compared to others of the same age?

2a Do you suffer from diabetes? (If �Yes�, is it under control and do you take insulin?)

Further details:


3 Have you noticed any change in your thirst or passing more urine?

Further details:


4 Have you had any unexplained weight loss/gain recently?

Further details:


5 Do you have heart disease of any sort, e.g. coronary artery disease or angina?

Further details:


6 Do you get chest pains?

Further details:


7 Do you experience shortness of breath, wheezing or bouts of coughing?

Further details:


8 Do you have asthma or chronic bronchitis?

Further details:


9 Have you had peptic ulcers or duodenal ulcers?

Further details:


10 Do you get frequent indigestion, heartburn, belching or have a bowel disorder?

Further details:


11 Have you had depression, �stress�, nervous disorders or other mental illness, alcohol or drug addiction?

Further details:


12 Do you have any condition requiring regular medication at strict times, e.g. epilepsy, thyroid disease?

Further details:


13 Do you suffer from any persisting fatigue or tiredness that does not go away after time off to rest?

Further details:


14 Do you have difficulty sleeping? (If �Yes� do you regularly use sleeping tablets?)

Further details:


15 Are you currently on any medication not already mentioned above? (If �Yes� please give details)

Further details:


16a Have you ever smoked? (If �Yes� for how many years and how many per day)

Further details:


16b Do you currently smoke?

Further details:


17 If female are your periods regular?

Further details:


18 If female are you pregnant? (If �Yes� which trimester?)

Further details:


19 Do you have any other condition not mentioned above? (please give details)

Further details:


20 Do you wish to see an Occupational Health Advisor/Doctor for any reason?

Further details:


Consent and Signature

It is your right under the Working Time Regulations to have a health assessment before being assigned to night/shift work and at regular intervals thereafter whilst a night/shift worker. This questionnaire is designed to identify any conditions that may affect your ability to do night/shift work. It should be passed on to the occupational health staff in the envelope provided to preserve the confidentiality of your reply. No medical details will be passed on to your manager other than a statement of fitness or unfitness. You can discuss in confidence your response to the questionnaire with an Occupational Health Advisor.

Information contained within this document is governed by the Data Protection Act 1998 and the Equality Act 2010. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. Disclosure of other information is only with your informed written consent. Deliberately providing misleading or inaccurate information may lead to disciplinary action, including possible dismissal.



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