Occupational Health QuestionnairePlease enable JavaScript in your browser to complete this form.All the information on the form will be treated in strict confidence and will not be divulged to any third party without written consent.Personal DetailsName *FirstLastDate *Branch *BedfordBedfordBrightonColchesterLondonLive inNorwichPeterboroughDepartment *StaffingCare at HomeComplex CareAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDate of Birth (DD/MM/YYYY) *Mobile *Email *Section A - Medical HistoryPlease answer all of the following questions. If you answer Yes please give details. Have you ever had or do you have now, any of the following?Impairment which may affect your ability to work safely? *YesNoDon't knowDetailsEyesight problems not corrected with glasses/contact lenses? *YesNoDon't knowDetailsHearing problems not corrected with a hearing aid? *YesNoDon't knowDetailsDifficulty in standing, bending, lifting or other movements? *YesNoDon't knowDetailsAny kind of back problem? *YesNoDon't knowDetailsHave you ever suffered discomfort when using a computer keyboard? *YesNoDon't knowDetailsAny mental illness or psychological problems e.g. depression nervouse breakdowns, eating disorder, substance misuse or other? *YesNoDon't knowDetailsA drug or alcohol problem? *YesNoDon't knowDetailsFits, blackouts or epilepsy? *YesNoDon't knowDetailsAny allergies? *YesNoDon't knowDetailsAsthma, bronchitis or chest problems? *YesNoDon't knowDetailsTreatment for TB? *YesNoDon't knowDetailsIn the last 12 months have you had a cough for more than 3 weeks, ever coughed up blood or had any unexplained loss of weight or fever? *YesNoDon't knowDetailsDiabetes, thyroid or gland problems? *YesNoDon't knowDetailsAny illness which may have caused or been made worse by your work? *YesNoDon't knowDetailsEpisodes of chest pain or breathlessness? *YesNoDon't knowDetailsSuffer from heart disease or high blood pressure? *YesNoDon't knowDetailsAre you at present taking or receiving any form of medication? *YesNoDon't knowDetailsAny operations? *YesNoDon't knowDetailsBeen retired on the grounds of ill health? *YesNoDon't knowDetailsAre you waiting for or receiving treatment for any medical or mental health *YesNoDon't knowDetailsHave you ever suffered with stress associated with work? *YesNoDon't knowDetailsIs there any additional relevant information regarding your health not covered in the above questions? *YesNoDon't knowDetailsSection B - Food HandlersYou have a duty to report to your employer of any changes to your health.Any skin conditions? (please specify) *YesNoDon't knowDetailsHepatitis or jaundice? *YesNoDon't knowDetailsDysentery, typhoid, paratyphoid, fever, food poisoning, salmonella, severe gastroenteritis or diarrhea? *YesNoDon't knowDetailsAny discharge from ears or current/recurrent ear infections? *YesNoDon't knowDetailsSection C - Sickness AbsenceHow many days have you lost from work or school during the past year? *What was this due to?Section D - Immunisations / Blood Test ResultsCertain jobs carry with them a risk of infection. In such cases we offer the facility of being immunised to prevent the risk of infection. Please provide details below of your immunisation history. When attending, please bring with you proof of identity e.g. passport or hospital identity badge.ImmunisationsHB test (Heaf, Tine, Mantoux)YesNoDon't knowDate dd/mm/yyResultsBCG [TB vaccinations]YesNoDon't knowDate dd/mm/yyResultsTetanusYesNoDon't knowDate dd/mm/yyResultsPoliomyelitisYesNoDon't knowDate dd/mm/yyResultsRubella [German Measles]YesNoDon't knowDate dd/mm/yyResultsHepatitis AYesNoDon't knowDate dd/mm/yyResultsHepatitis B (Date of last immunisation)YesNoDon't knowDate dd/mm/yyResultsMeningitis BYesNoDon't knowDate dd/mm/yyResultsBlood test resultsHepatitis BYesNoDon't knowDate (DD/MM/YYYY)ResultsRubella [German Measles]YesNoDon't knowDate dd/mm/yyResultsVaricella (Chicken pox)YesNoDon't knowDate dd/mm/yyResultsChest X-ray [clear)?YesNoDon't knowDate dd/mm/yyResultsOthersPlease stateDate dd/mm/yyResultsSection E - HIV/AIDSThe company operates a policy of non-discrimination. In line with company policy, and National Guidelines, 'HSC 1998/226 - Guidelines on the Management of AIDS/HIV Infected Health Care Workers and Patient Notification' (updated August 1999), you must inform the Director of Training and Quality if you know or suspect you are HIV positive or have an AIDS defining illness. This information is necessary in order that a Risk Assessment may be undertaken to your safety and that of others.If you know or suspect you are either HIV antibody positive or have AIDS, please tick the appropriate box. This information is absolutely confidential to the Director of Training and Quality.YesNoSection G - Night WorkersThe following section is to be completed only by those members of staff who regularly undertake night duty. Have you suffered from and been treated for any of the following. If Yes, please give details of the condition and whether they are ongoing at present.Blackouts/Fainting fits/EpilepsyYesNoBack or limb disordersYesNoDiabetesYesNoHeart or circulatory disordersYesNoStomach, bowel or intestinal disordersYesNoAny conditions affecting sleepYesNoAsthma/ bronchitisYesNoAnxiety/depressionYesNoNervous or mental disordersYesNoSerious operations/accident/injuriesYesNoDo you have any other ongoing health problem?YesNoAre you currently taking drugs or medicines prescribed by a doctor or purchased from a pharmacy?YesNoPlease give the name of the drug and dosageDo you consider that you have any form of medical condition that may affect your ability to work at night?YesNoPlease explainHave you ever felt that night work was harming your health?YesNoDo you wish to discuss anything with a health advisor?YesNoSection H - COVID-19 Vaccination StatusPlease select from the options below your current vaccination status for COVID-19.What is your current vaccination status? *First vaccinationFully vaccinatedNot vaccinatedSection I - DeclarationI declare that the information on this form is true to the best of my knowledge. Further, I understand that if I should be found to knowingly make a false statement regarding my medical history either in answering the above questions or to the Company's Director of Quality and Training, or should I conceal any material fact, the Company can terminate my contract without notice.CommentSubmit