Medical Questionnaire

Employee Medical Questionnaire

CONFIDENTIAL

The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by the Rainbow Creative Media and may need to be seen by an occupational health advisor or physician.

PERSONAL INFORMATION

Title:Date of Birth:
First Name:Surname:
Home Telephone:Mobile:
Work Telephone:Email*:
GP Address:
 

MEDICAL HISTORY

All staff groups complete this section

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?*

YesNo

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?*

YesNo

Are you having, or waiting for treatment (including medication) or investigations at present?*

YesNo

If your answer is yes, please provide further details of the condition, treatment and dates.

Do you think you may need any adjustments or assistance to help you to do the job?*YesNo

ADDITIONAL INFORMATION (If you have answered yes to any questions above please provide additional information below)

 

IMMUNISATIONS

Please indicate which off the following Immunisations you have been vaccinated against and include your vaccination reports when returning your registration.

EPP and Non EPP*Hep B:TB:Varicella:Measles:Rubella:

All applications who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost.

Rainbow Creative Media Providers will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate. Candidates will be required to purchase uniform if required at the cost of £20 this will be deducted from your timesheet once you have started working through us.

Please tick the box to acknowledge that you agree with the statements above.*YesNo
 

TUBERCULOSIS

Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006)

Have you lived continuously in the UK for the last 5 years?*YesNo
If you answered No above, please list all of the countries that you have lived in over the last 5 years
Have you had a BCG vaccination in relation to Tuberculosis?*YesNo
If you answered yes please state when
Date:
Do you have any of the following
A cough which has lasted for more than 3 weeks*YesNo
Unexplained weight loss*YesNo
Unexplained fever*YesNo
Have you had tuberculosis (TB) or been in recent contact with open TB*YesNo
ADDITIONAL INFORMATION (If you have answered yes to any questions above please provide additional information below)
 

CHICKEN POX OR SHINGLES

Have you ever had chicken pox or shingles?*YesNoDate:
 

IMMUNISATION HISTORY

Have you had any of the following immunisations?*

Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)*YesNoDate:
Polio*YesNoDate:
Tetanus*YesNoDate:
Hepatitis B (If Yes is ticked please give dates below)*YesNoDate:
Course:1: 2: 3:
Booster:1: 2: 3:
 

PROOF OF IMMUNITY

(Please send the following)
VaricellaYou must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity.
TuberculosisWe require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare).
Rubella, Measles and MumpsCertificate of “two” MMR vaccinations or proof of a positive antibody for Rubella Measles and Mumps.
Hepatitis BYou must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above.
 

EXPOSURE PRONE PROCEDURES

Will your role involve Exposure Prone Procedures*YesNo
 

DECLARATION

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for Rainbow Creative Media to make recommendations to my employer.

Full Name*:Date*:
 

If you are have finished completing the questionnaire, please click "Submit" below..