Pre-Employment Health Assessment - Royal Bournemouth Hospital

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MEDICAL HISTORY: Please answer all the questions below. If you answer “Yes”, please enter details inthe comments column, dates; treatment(s) and whether there are ongoing symptoms and if so whetheractivities at home or at work have been, or could be, affected. Use a separate sheet if required.INDIVIDUALS WITH HEALTH RELATED PROBLEMS WILL NOT BE DISCRIMINATED AGAINSTDo you suffer from or have you eversuffered from any of the following?1 Illness or injury requiring treatment orinvestigation in hospital?2 Circulatory conditions e.g. angina,heart attack, high blood pressure,anaemia, varicose veins, stroke,thrombosis, oedema, etc?3 Chest conditions e.g. shortness ofbreath, asthma, bronchitis, pleurisy,pneumonia, TB, emphysema orhabitual cough?4 Stomach or bowel trouble, ulcers,indigestion, gall bladder disease,jaundice, hernia?5 Kidney or bladder complaint,incontinence, prostate problems orblood in the urine?6 Recurrent headache, migraine,dizziness, fits, fainting, blackouts,and /or loss of balance?YES NO COMMENTS7 Any medical condition likely to causesudden incapacity or loss ofconsciousness?9 Dermatitis, eczema or other skindisorder?10 Diabetes?11 Ear, nose, throat, sinuses, or dentaldisorder?12 Eye conditions or disease e.g.glaucoma, loss of vision, doublevision or blurring?13 Have you ever had any mentalillness or psychological problems,including depression, anxiety,schizophrenia or self-harm? Pleasegive details in section D14 Have you ever suffered fromanorexia or bulimia?15 What is your weight?16 What is your height?17 Have you ever attempted suicide?18 Have you ever abused drugs, alcoholor other substances?19 Have you ever had seizures,epilepsy, blackouts, suddendizziness or loss of consciousness?FORMS/Pre Employment Health Questionnaire Version 2 14 July 2010 2
20 Tropical disease or any conditioncontracted abroad?21 Conditions affecting joints, musclesor ligaments eg arthritis, back orneck problems?22 Difficulty with driving/walking/normaldaily activities?23 Are you taking regular medication?24 Have you any medical conditionwhich you believe to have beencaused by, or made worse by work?25 To the best of your knowledge areyou in good health?26 Females only: Are you currentlypregnant or breast feeding?27 Have you any health problem orsymptoms at the moment?FORMS/Pre Employment Health Questionnaire Version 2 14 July 2010 3
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