"*" indicates required fields Step 1 of 5 20% This questionnaire will be CONFIDENTIAL to the Health Assured Occupational Health Team. 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. You may be contacted by the Health Assured team and may need to be seen by an Occupational Health Nurse or Doctor. We are an Equal Opportunities employer and applicants with disabilities are encouraged to apply for jobs. Candidate code cannot be confirmed or has expired or been cancelled- Please contact the person who issued the code to you.Employee DetailsName * REQUIRED First Last Any Previous or Alternative NameDate of Birth * REQUIRED DD slash MM slash YYYY Job Title * REQUIREDTitleMrMrsMsMxDrDaytime Tel: * REQUIREDEvening Tel:This field is hidden when viewing the formEmail * REQUIRED Home Address * REQUIRED Street Address Address Line 2 City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country General Practitioner DetailsGeneral Practitioner Name * REQUIREDGeneral Practioner Address * REQUIRED Street Address Address Line 2 City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your RolePlease indicate if the role is office based or active patient facing * REQUIRED Office based Active patient facing This field is hidden when viewing the formPost & School/Academy DetailsThis field is hidden when viewing the formPost Applied For * REQUIREDThis field is hidden when viewing the formName of School/Academy * REQUIREDThis field is hidden when viewing the formAge range to be taught * REQUIREDThis field is hidden when viewing the formDepartment * REQUIREDThis field is hidden when viewing the formStart Date DD slash MM slash YYYY This field is hidden when viewing the formPast Employment with AuthorityThis field is hidden when viewing the formHave you ever worked for the Authority before? * REQUIRED Yes No This field is hidden when viewing the form(If under a different name at the time please give previous name)Date(s) EmployedThis field is hidden when viewing the formName of Last Teaching Post (or initial teacher training college if newly qualified)This field is hidden when viewing the formAddress of Last Teaching Post Street Address Address Line 2 City County Postcode Please tick the appropriate box below and provide detailsHave you ever had any illness, medical problem or disability that may currently affect your ability to work safely? * REQUIRED Yes No Please provide details * REQUIREDHave you ever been treated in hospital? * REQUIRED Yes No Please give reason(s) and dates * REQUIREDHave you seen a doctor in the last year for any kind of health problem? * REQUIRED Yes No Please give reason(s) * REQUIREDAre you having any treatment or investigations of any kind at the moment? * REQUIRED Yes No Please provide details * REQUIREDAre you waiting for any treatment, operation or investigation? * REQUIRED Yes No Please provide details * REQUIREDHave you ever had any illness or health related problem that may have been caused or made worse by your work? * REQUIRED Yes No Please give reason(s) and job role. * REQUIRED Have you ever been medically retired from any job, or left any job because of ill health? * REQUIRED Yes No Please give reason(s) and job role. * REQUIREDHave you had any days off sick in the last 2 years? * REQUIRED Yes No Please give number of days and reasons to the best of your recollection. * REQUIREDDo you have any eyesight problems not corrected with glasses? * REQUIRED Yes No Please state how this affects you/ your ability to drive. * REQUIREDDo you have any hearing problems? * REQUIRED Yes No Please give details of how this affects you. * REQUIREDDo you have any difficulties standing, bending or with any other movements? * REQUIRED Yes No Please give details of how this affects you. * REQUIREDDo you have any difficulties lifting? * REQUIRED Yes No Please give details of how this affects you. * REQUIREDHave you ever had any back problem? * REQUIRED Yes No Please give details of how this affects you. * REQUIREDHave you ever had any problem with your joints including pain, swelling or stiffness? * REQUIRED Yes No Please give details of how this affects you. * REQUIREDHave you ever suffered from any mental illness, psychological or psychiatric problem, including depression, anxiety, nervous debility, nervous breakdown, schizophrenia or eating disorder? * REQUIRED Yes No Please give details of dates and medical interventions. * REQUIREDHave you ever had a drug or alcohol problem? * REQUIRED Yes No Please give provide details and dates. * REQUIREDHave you ever had fits, blackouts or epilepsy? * REQUIRED Yes No Please give details of how this is controlled, your last fit and ability to drive. * REQUIREDHave you ever had any skin problems? * REQUIRED Yes No Please give details. * REQUIREDHave you ever had any heart or blood pressure problems? * REQUIRED Yes No Please give details of how this is controlled or managed, including medication. * REQUIRED Have you ever suffered from asthma, bronchitis or chest problems? * REQUIRED Yes No Please give details. * REQUIREDIn the last 12 months, have you had a cough for more than 3 weeks, coughed up blood or had any unexplained weight loss or fever? * REQUIRED Yes No Please provide details. * REQUIREDHave you ever had hepatitis or jaundice? * REQUIRED Yes No Please provide details and dates. * REQUIREDDo you have any other medical conditions? * REQUIRED Yes No Please provide details. * REQUIREDAre you on any medication at present? * REQUIRED Yes No Please provide names, dosage and dates commenced. * REQUIREDDo you feel well at present? * REQUIRED Yes No Please provide details. * REQUIREDAre you allergic to anything? * REQUIRED Yes No Please provide details * REQUIRED DeclarationI declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I understand that if any recommendations to my employer are necessary as a result of this Work Health Assessment, Health Assured will discuss the recommendations with me before making them available to my employer. I agree to my information being stored and processed by Health Assured Occupational Health staff in a confidential manner according to the Data Protection Act. If you wish to access your records please request a Data Subject Access Request by contacting us. There may be a small administration charge for this.Please enter name as a signature * REQUIREDDate * REQUIRED DD slash MM slash YYYY
