Fillable Printable Confidential Health Questionaire - Chesterfield
Fillable Printable Confidential Health Questionaire - Chesterfield
Confidential Health Questionaire - Chesterfield
OCCUPATIONAL HEALTH DEPARTMENT
CONFIDENTIAL HEALTH QUESTIONNAIRE
Work Experience / Placement
THIS SECTION FOR OFFICE USE ONLY
Full name: …Michelle Day……… …… Post: ………PA…………………………………
Department: ………Education……………………… Extension: ……3738…………………….….
Signature: ……………………………………………… Date handed to applicant: …………………..….
Area of work experience / placement: ………………………………………………………………………..
Dates of attendance, From: …………………….. To: …………………….. Day(s): ……………………..
Hours: ……………………………………………...
THIS SECTION TO BE COMPLETED BY THE APPLICANT IN PRINT
Surname: ……………………………………………… Forename(s): ……………………………………
Title (please circle): Dr / Mr / Mrs / Miss / Ms Date of birth: ……………………………………..
Address: ………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………..
……………………… Postcode: ……………………. Telephone: ……………………………………….
Do you have or have you ever had any of the following:
Yes / No
1. Any serious infectious diseases?
2. Stomach, bowel problems, infections or food poisoning?
3. Asthma, tuberculosis or other chest problems?
4. Any allergy (including hay fever)?
5. Fainting, blackout(s) or epilepsy?
6. Any vision problem(s) not corrected by glasses?
7. Ear problems, infections or hearing defect?
8. Dermatitis, eczema or any skin problems?
9. Joint or back problems?
10. Any disability?
11. Depression / nervous / mental illness or anorexia / eating disorders?
12. Are you diabetic?
13. Are you taking any medicines or tablets?
14. Any other health problem?
If you answered ‘YES’ to any of the above, please give full details (including names of any
medication) on a separate piece of paper and attach it to this application.
VACCINATION / IMMUNITY HISTORY
Details of your vaccinations / immunities may be important to your placement.
Please provide as much detail as possible.
Tuberculosis (TB);
Have you had the BCG vaccination? Yes / No Date of vaccination ……….…………..
Tetanus* Yes / No Date of last vaccination ……….…………..
Polio* (Poliomyelitis) Yes / No Date of last vaccination ……….…………..
Rubella* Yes / No Date of last vaccination ……….…………..
Hepatitis A Yes / No Date of last vaccination ……….…………..
Hepatitis B Yes / No Date of all vaccinations ……….…………..
MMR Yes/No Date of all vaccinations ……………………
*If the answer to these is ‘NO’, you are advised to contact your GP and have these ch ecked prior to
your visit. If you have had immunity checks for Hepatitis B, Rubella and TB in the past please send
copies of these tests with this form or give details of where and when the tests were done.
INFECTIONS
Have you had the following or had recent contact with:
Chickenpox Yes / No Date ……….…………..
German Measles Yes / No Date ……….…………..
Tuberculosis Yes / No Date ……….…………..
Hepatitis A Yes / No Date ……….…………..
MRSA Yes / No Date ……….…………..
Any other infectious disease(s)?……………………………………………………………………………….
……………………………………………………………………………………………………………………..
DECLARATION
I, …………………………………………………………………, understand that the Work Experience /
Placement if offered will be subject to the information given on this form being correct to the best of
my knowledge and belief. I am aware that my Work Experience / Placement may be cancelled if I
am found to have given any false statements.
Signature ………………………………………………………………… Date ………………………………
A Parent or Guardian must complete the next section:
I, …………………………………………………………………, am the *Parent / Guardian of the above-
named. I agree to my *Son / Daughter / Ward attending the Occupational Health Department for a
health interview and *agree / disagree to blood tests being carried out, if required.
For some placements the applicant may be required to attend the Occupational Health Department
for a health interview and investigations, including blood tests for Rubella, Hepatitis B and TB.
Signature ………………………………………………………………… Date ………………………………
*delete as applicable
