HEALTH QUESTIONNAIRE

The information on this form will remain confidential to the Occupational Health Service and will be held securely within the department unless otherwise agreed by you. The information will be assessed by an Occupational Health practitioner who will advise Human Resources of the outcome of the assessment. You may be asked to provide additional information or asked to attend the Occupational Health Department prior to commencing employment. When fully completed, please return this form to the Occupational Health Department at the site below. Failure to complete and return the questionnaire will result in it being returned to you and may delay your starting date. Post Appointed to: .. Department: ... Human Resources contact name: .... . E-mail address: ....... Hospital: . Site: .

Mr/Mrs/Miss/Ms/Dr/Prof/Sir/Rev

Male/Female

Please indicate if you have ever worked for any of the following organisations and the year you left:

Date of Birth:

Surname:
(Block Capitals)

Bromley NHS Trust

Bromley PCT

First Names:

Queen Marys Sidcup NHS Trust

Maiden Name (if applicable):

Home Address:

Bexley Care Trust

Queen Elizabeth Woolwich NHS Trust

Post Code:

Email:

Greenwich PCT

Home Telephone No:

Year left:

Mobile Telephone No:

Have you had:

Histo ry of Infect ion

Docu ment ation of blood test indic ating Immu nity No

Immunis ation

Dates (of infection, blood tests and/or immunisa tions)

Yes

Yes

No

Yes

No

Measles

Mumps

Rubella

Chicken Pox

Hepatitis B
If your job will involve exposure prone procedures, you must attach copies of identified sample test results of HBsAg and antiHbs from a UK laboratory

Primary Course

Boosters

Hepatitis C

HIV

Tuberculosis

BGC vaccination

Heaf/Mantoux test

Result

Any applicant whose work involves exposure prone procedures (EPP) who commenced EPP work after August 2002 must provide valid documentation of their Hepatitis C status. Applicants commencing EPP work after March 2007 must provide valid documentation of their HIV status. This documentation must be returned with this health questionnaire. Any successful applicant who has not provided appropriate documentation will not be permitted to undertake EPP work until valid results have been obtained through the Occupational Health Department. Please attach copies of all immunisation details and blood test results and bring photo identification to all Occupational Health appointments

Infectious Diseases/Blood Borne Viruses

Do you have any reason to believe that you are, or may be, infected with HIV, hepatitis B, hepatitis C, or any other infectious disease? (All employees have a legal and ethical duty to inform Occupational Health if this is the case) YES/NO (Delete the inapplicable)

If you answer Yes to any of the questions below, please give dates and details and continue on a separate sheet of paper if necessary.

YES
Are you currently receiving treatment of any kind from your GP, hospital specialist, or other health practitioner (including complementary therapists) awaiting or undergoing investigations?

NO

DATES & DETAILS

Have you ever had an illness, medical problem or injury that may currently affect your ability to work in the post for which you have applied?

Have you ever had any health problems that have caused you difficulty with sitting, standing, bending, lifting, carrying, or working with a computer? Have you ever had any mental health problems (Including anxiety, depression, nervous breakdown, stress, eating disorders, self-harm, addictions)? Have you ever had rhinitis, hayfever, asthma or any chest/breathing problems?

Have you ever had any skin problems e.g. eczema, psoriasis, recurrent skin infections, allergic rashes?

Do you have any difficulties with your vision, hearing or mobility?

Have you had any days away from study or work due to illness or injury in the last 2 years? Please give number of days and reasons to the best of your recollection.

A failure to declare a known condition or any current/ongoing investigation which may result in risk or harm being put to patients or other members of staff, will result in action being taken against you and referral to your regulatory body.

Signature of Applicant: Date: .

OCCUPATIONAL HEALTH USE ONLY

Outcome
(enter full details on Cohort and fit form)

Date

Name & Signature of OH Practitioner

Fit for post Fit for EPP Fit for post but not fit for EPP until OH clearance Fit with adjustments Adjustment details Further information required

Pre-employment health interview Pre-employment medical assessment Human Resources Clearance Sent to: