ࡱ> 02-./u@ bjbj 8 $2o2o2o2o$Vp&r fD8::::::$Rٝ^^?vvv8v8vv,,r wX2o,U0,]H],,]@dv^^6n95H.n9ST LUKES HOSPICE CONFIDENTIAL HEALTH QUESTIONNAIRE Clinical details on this questionnaire are confidential to the Occupational Health Department. However, general advice based on it will be given to the Hospice on your fitness to work. Failure to disclose information or knowingly make a false statement may have implications for your future employment within the Hospice. Click in the grey boxes and type your answer or choose from the drop-down options. When complete, save the result as a Word file and send it with the employment application form as an e-mail attachment to: personnel@stlukes-hospice.org Personal Details Surname:  FORMTEXT       Title: FORMDROPDOWN  First Names: FORMTEXT       Male  FORMCHECKBOX  / Female  FORMCHECKBOX  (click in the appropriate box) Former/Maiden Name: FORMTEXT       Date of Birth: FORMTEXT       Home Address: FORMTEXT       Home Telephone No:  FORMTEXT       Daytime Telephone No:  FORMTEXT       GP s name:  FORMTEXT       GP s Telephone No:  FORMTEXT       GP s Address:  FORMTEXT       Post applied for: FORMTEXT       Department:  FORMTEXT       Permanent or temporary?  FORMDROPDOWN  If temporary please indicate length of contract:  FORMTEXT       Employment History: Name of employer Post Held Date of employment 1. FORMTEXT        FORMTEXT        FORMTEXT       2. FORMTEXT        FORMTEXT        FORMTEXT       3. FORMTEXT        FORMTEXT        FORMTEXT       4. FORMTEXT        FORMTEXT        FORMTEXT       5. FORMTEXT        FORMTEXT        FORMTEXT       6. FORMTEXT        FORMTEXT        FORMTEXT       Please answer EVERY question. Select  YES or  NO as appropriate. If the answer is  YES please give brief details. HAVE YOU EVER HAD:BRIEF DETAILS OF ALL PAST & PRESENT CONDITIONSDATES1. Severe headaches or migraine FORMDROPDOWN  FORMTEXT       FORMTEXT      2. Fits, convulsions or epilepsy FORMDROPDOWN  FORMTEXT       FORMTEXT      3Depression, anxiety or mental ill health  FORMDROPDOWN   FORMTEXT       FORMTEXT      3aAny attempts at self-harm  FORMDROPDOWN   FORMTEXT       FORMTEXT      3bAn eating disorder (e.g. anorexia, bulimia) FORMDROPDOWN   FORMTEXT       FORMTEXT      3cCounselling, psychotherapy or psychiatric treatment FORMDROPDOWN   FORMTEXT       FORMTEXT      3d.A problem with alcohol consumption or other substance misuse FORMDROPDOWN   FORMTEXT       FORMTEXT      4.Eye conditions, injuries or serious defects of vision not corrected by lenses FORMDROPDOWN  FORMTEXT       FORMTEXT      5.Ear infections, discharge, hearing loss/deafness FORMDROPDOWN  FORMTEXT       FORMTEXT      6.Frequent sore throats or sinusitis  FORMDROPDOWN  FORMTEXT       FORMTEXT      7. Asthma, hayfever, allergies (including antibiotics)  FORMDROPDOWN  FORMTEXT       FORMTEXT      8.Bronchitis, pneumonia or chronic lung condition  FORMDROPDOWN  FORMTEXT       FORMTEXT      9.Lung tuberculosis FORMDROPDOWN   FORMTEXT       FORMTEXT      9aCoughing up blood  FORMDROPDOWN   FORMTEXT       FORMTEXT      9b.Cough for more than 3 weeks in the last year FORMDROPDOWN   FORMTEXT       FORMTEXT      10.Heart disease, angina, raised blood pressure or circulation disorders  FORMDROPDOWN  FORMTEXT       FORMTEXT      11. Blood disorders e.g. sickle cell disease, haemophilia or anaemia  FORMDROPDOWN  FORMTEXT       FORMTEXT      12. Dysentery, typhoid fever, food poisoning, gastro-enteritis or chronic diarrhoea FORMDROPDOWN  FORMTEXT       FORMTEXT      13 Frequent/severe indigestion or gastric/duodenal ulcers FORMDROPDOWN  FORMTEXT       FORMTEXT      14. Hernia  FORMDROPDOWN  FORMTEXT       FORMTEXT      15.Excessive weight gain or loss  FORMDROPDOWN  FORMTEXT       FORMTEXT      16. Diabetes  FORMDROPDOWN  FORMTEXT       FORMTEXT      17.Kidney or bladder (urinary) condition/infection FORMDROPDOWN  FORMTEXT       FORMTEXT      18.Severe back, neck pain or disc trouble  FORMDROPDOWN  FORMTEXT       FORMTEXT       19.Difficulties in bending or lifting  FORMDROPDOWN  FORMTEXT       FORMTEXT      20.Varicose veins or foot problems  FORMDROPDOWN  FORMTEXT       FORMTEXT      21.Eczema, dermatitis or other skin conditions  FORMDROPDOWN  FORMTEXT       FORMTEXT      22.Any disorder of the immune system requiring treatment with steroids  FORMDROPDOWN  FORMTEXT       FORMTEXT      22a.Splenectomy  FORMDROPDOWN  FORMTEXT       FORMTEXT      23.Have you ever had chickenpox?  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FORMDROPDOWN  FORMTEXT       FORMTEXT      25.Have you had any operations or are you on a hospital waiting list? (please specify) FORMDROPDOWN  FORMTEXT       FORMTEXT      26. Have you had any accident resulting in severe injury?  FORMDROPDOWN  FORMTEXT       FORMTEXT      27.Are you taking any medication/drugs?  FORMDROPDOWN  FORMTEXT       FORMTEXT      28.Are you attending your GP or a specialist on a regular basis?  FORMDROPDOWN  FORMTEXT       FORMTEXT      29.Have you had any work related illness?  FORMDROPDOWN  FORMTEXT       FORMTEXT      30.Have you ever left or changed any job due to ill health?  FORMDROPDOWN  FORMTEXT       FORMTEXT      31.Do you have a disability?  FORMDROPDOWN  FORMTEXT       FORMTEXT      32.Any other conditions or health problems? FORMDROPDOWN  FORMTEXT       FORMTEXT       Have you had a chest X-ray?  FORMDROPDOWN  Date:  FORMTEXT       Result:  FORMTEXT       Do you smoke?  FORMDROPDOWN  If  yes how many per week:  FORMTEXT       Do you drink alcohol?  FORMDROPDOWN  If  yes how much per week  FORMTEXT       Current weight:  FORMTEXT       Current height:  FORMTEXT       Number of days/weeks absence from work in the last year due to illness or injury.  FORMTEXT       Please give reasons:  FORMTEXT       To the best of my knowledge and belief my answers to the above are true and complete. I acknowledge that failure to disclose information may result in termination of my contract. I understand that subject to information supplied, I may be invited to attend the Occupational Health Department for an interview/further health assessment and subject to my approval, my GP/Hospital Doctor may be approached for further information. Entering your name here will be taken as equivalent to your signature:  FORMTEXT       Date:  FORMTEXT       IMMUNISATION DETAILS Name in full:  FORMTEXT       Date of Birth:  FORMTEXT       Have you been immunised against or tested for the following? Tuberculin skin test method (e.g. Heaf)Date:  FORMTEXT       Grade  FORMTEXT       Tuberculosis (BCG)Date:  FORMTEXT       Scar size in mm  FORMTEXT      Rubella (German Measles) immunisation Rubella antibody screenDate:  FORMTEXT       Date:  FORMTEXT       Result: FORMTEXT      Varicella (chickenpox) antibody screenDate:  FORMTEXT       Result: FORMTEXT       Tetanus  Primary course dates: 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT      Booster dates: 1. FORMTEXT       2. FORMTEXT      Polio  Primary course dates: 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT      Booster dates: 1. FORMTEXT       2.  FORMTEXT      Hepatitis B Primary course dates: 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT      Booster dates: 1. FORMTEXT       2.  FORMTEXT      Hepatitis B antibody titre date:  FORMTEXT       Result (mlU/ml)  FORMTEXT      Typhoid  Primary course dates: 1.  FORMTEXT       2.  FORMTEXT      Booster dates: 1.  FORMTEXT       2.  FORMTEXT      Hepatitis A Primary course dates: 1.  FORMTEXT       2.  FORMTEXT      Booster dates: 1.  FORMTEXT       2.  FORMTEXT       ALL STAFF WHO PERFORM EXPOSURE PRONE PROCEDURES ARE REQUIRED TO SUBMIT LABORATORY DOCUMENTARY EVIDENCE OF HEPATITIS B STATUS PRIOR TO COMMENCING EMPLOYMENT To the best of my knowledge and belief, the answers above are true and complete. I hereby give permission for the Occupational Health Department to contact my previous employer s Occupational Health Department to obtain information on past immunisation. 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