Health declaration questionnaire information


Previous employment details



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Previous employment details


Please list your employment details for the past 10 years starting with your present employment.

Dates: From


To

Employer/Dept/Unit


Specific Workplace Hazards































































Your health details - confidential

Height Weight ______st/ lbs or Kgs


Alcohol – Units per week ______


  • During the past two years how many occasions have you taken sick leave from work or training / education? _________




  • Approximately how many days in total does this amount to? days




Have you ever had

YES



NO

If YES please give brief details including dates (continue on a separate sheet if required)

Have you ever had a work-related injury and/or disease?










Do you have a disability, which may require adaptation of work place or work schedule?










Have you previously left a job / training on grounds of ill health?










Have you had any major accidents?










Have you ever been admitted to a hospital of any kind for treatment?










Have you ever attended an out-patient clinic?










Have you attended a casualty department in the last five years?










If ‘Yes’ how many times and for what reason.










Do you regularly need to consult your General Practitioner?










If ‘Yes’ with what conditions / problems.










Are you presently on any medication? If so what?










Have you lived or worked abroad during the past five years?










Have you ever been found to be unsuitable for healthcare work?












Have you ever had



YES

NO


If YES please give brief details including dates (continue on a separate sheet if required)

A mental health condition, e.g. anxiety, eating disorder, mood disorder, depression, hypomania, suicide attempts, self harm, schizophrenia?










Any history of stress and/or counselling?










Consultation and/or treatment in a Mental Health Clinic or had counselling?










Drugs or alcohol dependence?










Epilepsy, fits blackouts, fainting attacks, or recurrent dizziness?










Heart problems or high blood pressure?










Kidney or bladder problems?










Gastric / duodenal ulcer or bowel problems?










Persistent / recurrent attacks of diarrhoea / vomiting / abdominal pain?










Recent unexplained weight loss?










Jaundice or hepatitis?










Hernia or varicose veins?










Persistent / recurrent backache, sciatica, disc or other back problems?










Problems with your neck, shoulders, arms, hands / wrists?










Other joint problems such as arthritis or rheumatism?










Deformities or problems affecting movements?










Tuberculosis (TB), recurrent cough, blood stained sputum, night sweats, unexplained weight loss?










Chest problems, breathing difficulties, wheezing or recurrent bronchitis?










Asthma, hay fever or allergy to anything?

(e.g. Latex)












Migraine / persistent headaches?










Persistent ear problems or hearing defect?










Eye problems or vision defect?










Diabetes, thyroid or gland problems?











Any other significant health problems / operations not mentioned above?










Have you ever been in positive contact with MRSA (Methicillin Resistant Staphylococcus Aureus) in the last six months or ever been positive?










Do you need any extra facilities and/or support to attend the Occupational Health department for further assessments?













Not confidential – immunisations and infection diseases

The following information may be passed on to other Occupational Health Departments and / or your manager for infection control purpose to protect you and your patients

Have you ever had chicken pox or shingles? YES / NO
Have you had Varicella blood test? If YES please give result: Immune / Non immune
Have you been in contact with anyone suffering with TB in the past three years? YES / NO

If YES give details.


If in doubt about dates, please check with your GP and / or Occupational Health Service.

TB – BCG

Heaf or Mantoux test (most recent)




Date
Date


Scar present Yes  No 

Result

Rubella Immunisation (German Measles)



Date

Blood Screening Date Result

MMR (Measles Mumps & Rubella)

Date

Date

Polio - primary course

Date

Last Booster Date

Tetanus - primary course

Date

Last Booster Date

Pol/Dip/Tet (Polio, Diphtheria & Tetanus)

Date

Last Booster Date

Hepatitis A - primary course

Date

Last Booster Date

Hepatitis B - Full course completed

Date

Last Booster Date

- Last Blood test

Date

Result:

Hepatitis C Antibody Test

Date

Result : Positive / Negative

Varicella Vaccine

Dates 1st

Date 2nd

Meningitis C

Date

Date



Declaration


I certify that the answers to the aforementioned questions are correct to the best of my knowledge. I give consent to be examined if necessary*. I am aware that failure to make a full declaration of health may lead to dismissal. I understand that no medical details will be divulged without my permission to any person outside the Occupational Health Service, but an opinion about my fitness for work will be given to the admissions officer.
*Please note midwifery and paramedic students will always need to be seen by Occupational Health to confirm fitness prior to commencement of course. This is a requirement from the Department of Health with regard to screening for blood borne viruses.
SIGNED _____ ____ DATE_____

For occupational health use only

For Health Interview with OH Nurse Adviser  Medical with OH Physician 

GP Health Questionnaire received YES / NO
Fit for Post 
Documented evidence of Hepatitis B immunity required 

Documented evidence of Hepatitis B immunity supplied 


SIGNED DATE


GP Health Questionnaire for Prospective

Pre-registration Healthcare Students

Dear Doctor


The person who has brought you this letter has accepted a place on a pre-registration healthcare course in the School of Health at The University of Northampton.
Following the publication of the Clothier Report recommendations, applicants for pre-registration healthcare training are required to provide a report from their general medical practitioner before an appointment can be considered. I should be most grateful, therefore, if you would complete the questionnaire below and return it to the applicant, who will be required to meet any cost incurred.
Thank you for your co-operation.
Admissions

The University of Northampton

Name of Applicant
Does the above person suffer or have ever suffered from:
Psychological/psychiatric symptoms YES/NO

An eating disorder including anorexia or bulimia nervosa YES/NO

Alcohol or drug problems YES/NO
Is there a history of frequent attendance at GP surgery or A & E Dept YES/NO

Deliberate self harm YES/NO

Personality disorder YES/NO
What, if any, treatment is currently being given?

Signature of GP: -------------------------------------------- Date: -------------------


Address--------------------------------------------- GP Stamp
------------------------------------------------------

I, the undersigned, agree for this information to be provided by my GP to the relevant Occupational Health Department as a requirement of my application for pre-registration healthcare training.


Signed………………………………….. Print Name……..…………………………. Date………………….
(Revised October 2006)

Host site addresses


Nursing and Midwifery students:
You should return your forms to the Occupational Health Department at your host site and mark the envelope as confidential.
Occupational Health Department

Warren Hill House

Kettering General Hospital NHS Trust

Rothwell Road

Kettering

NN16 8UZ
Occupational Health Department

Acorn Centre

Milton Keynes General Hospital NHS Trust

Standing Way

Eaglestone

Milton Keynes

MK6 5LD
Occupational Health Department

Northampton General Hospital NHS Trust

Billing House

Cliftonville

Northampton

NN1 5BD

All other students:


Send both the above questionnaires to the Occupational Health Department at Northampton General Hospital at the address above marking the envelope as confidential.

- HQ




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