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: 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


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


Do you require any reasonable adjustment to the work environment?

If yes, please describe:



Have you ever suffered or claimed for an industrial injury?

If yes, please describe (e.g. any on-going effects) and date of claim:


Have you previously been screened for any of the following?

If yes to any, please give approximate dates and information if any treatment or changes to your job were advised.

Noise/hearing test

Vibration (HAVS/"white finger")

Skin problems associated with work

Lung function/breathing test


How many days were you absent due to sickness during the past two years?

How many periods of sickness absence were there? (e.g. 6 single days counts as six, but two weeks for recovery after an operation counts as one)

Do you take regular exercise?

Do you have a valid driving licence?

Do you require glasses for driving?

Have you ever been advised by a doctor to inform the Vehicle Licensing Authority of a health or medical condition, which is relevant to holding a driving licence?

If yes, please state:

Do you drink alcohol?

How much do you drink?

Medical History/Health Status

In your opinion, are you in good health?

Are you receiving or have you recently received any form of medical treatment?

Have you been diagnosed with any form of disability?

If yes to either of the last three questions, please give details:

Please give details of any medication you are currently taking:

Have you been absent from work for ten days or more during the past year as a result of any medical condition?

Have you ever had to give up a job for medical reasons?

If yes to either of the last two questions, please give details:


Do you suffer or have you ever suffered from any of the following:

Heart problems (angina, heart attack etc.)?

Chest pains?

High blood pressure?

Diabetes?

If yes to Diabetes, is it under control/do you take insulin?

Bowel problems?

Liver/kidney/gall-bladder disorder?

Any change in your thirst or passing of urine?

Any unexplained weight loss/gain?

Stomach problems (e.g. frequent indigestion/heartburn/belching)?

Disease of the reproductive system?

Epilepsy?

Other neurological disorder (e.g. stroke, migraines)?

Mental disorder (e.g. anxiety, depression, stress, other)?

Back problems?

Muscle, tendon or joint problems of the arms or legs?

Sleep disorder (e.g. persistent insomnia or sleep apnoea)?

Drug or alcohol misuse (or addiction)?

Any medical condition causing a sudden loss of consciousness/incapacity/loss of concentration or vision?

Hernia/rupture?

Any serious accident/injury?

Deafness/ear disorder?

Eye diseases/disorders?

Any medical condition/operation/treatment not already mentioned above?

If you have answered yes to any of the above questions or anything else, please give brief details - including dates/duration of illness/treatment/referral to a specialist etc:

Audiometric Questionnaire

Noise

Do you believe you have been exposed to excessive noise (>85dBA) at work?

Have you had any noise exposure within the last 16 hours?

Have you had any noise exposure from leisure activities? (eg, sporting activities, night clubs)

Medical History

In your opinion, do you have difficulty with your hearing?

Have you ever been knocked unconscious?

Suffered from dizziness or vertigo?

Suffered from an illness that affected your hearing?


Have you suffered from any of the following?

Pain in the ears?

Running ears?

Ear infection?

Ear injury?

Perforated eardrum?

Tinnitus (ringing in the ears)?

Have you ever been exposed to gunfire or explosions?

Have you ever been referred to an ear/nose/throat Consultant?


Hearing Protection

Did you wear hearing protection before joining the company?

What type of protection did you use?

Did you wear hearing protection when advised to do so?

Type of hearing protection worn now?

Have you been trained to use your hearing PPE?

Lung Function Questionnaire

Do you have or have you ever had any of the following conditions?

Bronchitis?

Pneumonia?

Pleurisy?

Pulmonary Tuberculosis?

Asthma?

Hay Fever?

Heart Problems?

Phlegm?

Watery Eyes?

Rhinitis?

Chest tightness/or shortness of breath caused by dust?

Other chest problems?

In the last 12 months have you suffered from any of the following?

Wheezing?

Chest tightness?

Spontaneous shortness of breath?

Shortness of breath at night?

If you answer yes to any of the previous questions please give details below:

Have you noticed any difference in the symptoms when you are away from work? e.g. days off/holidays.

If you answered yes, please give details below:

Do you have any known allergies?

If you answered yes, please give details below:

Do you have any pets?

Have you ever smoked?

Do you currently smoke?




Have you ever tried to give up smoking?

Exposure to Hazards at Work or Home

Are you or have you ever been exposed to any of the following substances at work or at home?

Welding fumes?

Epoxy resins?

Silica dust?

Asbestos dust?

Lead dust?

Wood dust?

Filler dust?

Silica?

Asbestos?

Other


Personal Protective Equipment Used

Please describe which PPE you use at work or home:

Hearing

Have you received training in the use of your PPE?

Respiratory

Safety Glasses

Hands

Other

Skin Questionnaire

Do you currently have any known allergies or skin condition?

If yes please give details:

How long have you had it?

Is it better when you have been away from work for a period of time?

Is it worse doing any particular type of work or leisure activity?

Have you ever consulted your GP or specialist about any skin condition?

If so, please give details of any investigations or treatment given:

At work do you come into contact with any substances that are known to be hazardous to the skin?

If so, please give details:

Please give details on where you have or have had any skin problems:

Head?

Torso?

Legs?

Face?

Arm?

Foot?

Neck?

Hand?

Hand Arm Vibration Questionnaire

Only complete this section if operating vibrating tools at work.

Have you ever had a serious injury to your neck, arm or either hand?

If you answer yes, please give details:

Have you ever had an operation on your neck, arm or hand?

If you answer yes, please give details:

Do you have poor circulation?

Have you ever been told that you have any of the following:

Raynaud's Disease?

Vibration White Finger?

Carpal Tunnel Syndrome?

If you have answered yes to any of the above please give details below:

Do you use or have you ever used vibrating tools as part of your job or leisure activities?

If you have answered yes to any of the above please give details below:

Do you ever experience blanching (white fingers) tingling or numbness in either hand?

If so please give details:

Display Screen Equipment

To include Laptops/Desk Top Computers/Mobile Phones/Tablets
(Only complete if using any of the above for more than 1 hour a day)

How long have you been using DSE?

On average:

A) How many hours each day do you use DSE?

B) How long is a typical session?

C) Do you take any scheduled or unscheduled breaks?

D) How long is a normal break?

E) How many hours a day do you use a computer for leisure?

Please tick which best describes your own use of DSE:

When you are inputting do you work mainly with:

Do you suffer from headaches?

If yes, how often?

Do you suffer from sore eyes?

Do you experience pain/tingling/swelling in your forearms/hands or fingers?

If yes, how often?

Do you use a computer / display screen equipment at home?

If Yes, is it for work purposes?

If yes, have you completed your own DSE risk assessment for your workstation?

Consent and Declaration

Information contained within this document is governed by the General Data Protection Regulation 2016/679 and the Equality Act 2010.
I give permission for the following:
- To be contacted by a health professional to contact me by telephone, email and postal address if further information and/or update is needed.(please delete if you don’t agree to any of these)
- For my employer to be informed of essential information regarding my health, hazards and risks of my employment, with due reference to other relevant statutory requirements and professional practice.

I agree to inform my employer of any health problems so that my health and safety can be protected whilst at work.

Employee Signature (parent or guardian if under 18 years old).


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