Medical Questionnaire Sept 06

MEDICAL QUESTIONNAIRE Personal Details

To be completed by employee

Surname Forname DOB

Address

Postcode Tel No Name/Address of GP

Tel No

Medical History (Do you have, or have you had in the past, any of the following conditions?) Conditions of the lungs? Asthma? Bronchitis? Pleurisy, Tuberculosis? Other chest complaints? Coughing up blood? Shortness of breath? Conditions of the ears, nose and throat? Sinus trouble? Frequent colds & sore throats? Ear infections? Hearing deficiency? Any heart condition? Rheumatic feaver? Shortness of breath? High blood pressure? Heart attacks? Poor circulation? Chest pain on exertion? Blood disorders? Anaemia? Unexpected bruising? Nervous system diseases? Blackouts? Epilepsy? Muscular weakness? Headaches? Paralysis? Loss of sensation? Tingling or numbness of limbs? Conditions of the digestive system? Indigestion? Abdominal pain? Gastro/duodenal ulcer? Constipation? Diarrhoea? Bleeding from the stomach or bowel? Liver complaints/Jaundice? Conditions of the kidneys or bladder? Urinary infections? Blood in the urine? Kidney stones? Any sexually transmitted diseases? Are there any factors which place you at risk of infection by the AIDS virus? Conditions of the bones & joints? Arthiritis? Rheumatism? Backache or pains? Sciatica? Strains & sprains? Repetitive strain injuries (eg. Tennis elbow, tenosynovitis)? Hayfever or allergic conditions (including allergies to drugs)? Skin conditions? (ie. Exzema, porisis, etc) Anxiety/depression, mental breakdown or stress related problems? Or any other mental illness? Have you ever been medically dischaged from the Armed Forces/Police Force/previous employer?

Yes No

Details

Yes

Details

No Yes No

Details

Yes No Yes No

Details

Yes No

Details

Yes No Yes No

Details

Yes No

Details

Yes No Yes No Yes No Yes No

Details

Details

Details

Details Details Details

Employee's Signature The information I have provided is accurate an I have not withheld any details. I understand that the giving of false information or withholding information could subsequently result in my dismissal. I will notify you if any of my answers change. Signed

Name

Date

Doctor's Signature I confirm that I have seen/have not seen the patients medical notes and that the above information is true to the best of my knowledge. (delete as appropriate) Signed

Name

Date

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MEDICAL QUESTIONNAIRE To be completed by Doctor Date of examination

Name of Doctor

Height

Ideal weight

actual weight

B.P.

P.R.

P.E.F

Urine

Hands

Feet

Ears L Ears R

Eyes R Eyes L

Near Near

Lenses/Glasses

Far Far Yes/No

Throat

Mouth

Lungs

Heart

Abdomen

Circulation

Breasts

Lymph Nodes

Eye colour

Vitalograph Skin Neck Back Joints Spine Tone

Power

Reflexes

Sensation

Coordination

Balance

Scars/Deformities General Appearance

Have you seen this persons full medical notes?

Yes/No

How long has this person been been your patient?

Yrs

Months

Any other comments:

After full examination I find this person to be fully fit. Signed

Name

Date

Surgery Stamp:

Should you have any queries regarding this document please do not hesitate to contact Armor Group Welfare Coordinator on +44(0)20 7808 5887 or [email protected]

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