our expertise is working for you Medmark

Recurrent Medical Assessment Form

Cabin Crew Medical Assessment Form in Accordance with EU-OPS Regulations

Part A: INTRODUCTION

Under EU OPS Regulation 1.995 each operator has a legal requirement to ensure that each cabin crew member has passed a medical examination or assessment at regular intervals as defined by the Irish Aviation Authority (IAA) so as to check the medical fitness of their cabin crew to discharge their duties. IAA policy in compliance with EU-OPS with regards to cabin crew medical assessments defines regular intervals as every 60 months (5 years).

Purpose

The purpose of the medical questionnaire is to enable Medmark:
1. Establish the fitness of applicants to safely carry out duties of the intended position whilst ensuring compliance with EU OPS Regulations
2. Assess your ability to carry out the job without any undue risk to the health and safety of yourself, your colleagues, and your passengers
3. Form the basis of an occupational health record to be held by Medmark. This record may be referred to if the applicant is referred to Medmark at a future date.

Data Protection

The information on this document may be stored in either paper or electronic form. It is for the use of the occupational health assessment of cabin crew. The data will be held in accordance with Data Protection Legislation. The medical information stored will be treated as strictly confidential at all times by Medmark and will not be disclosed to any third parties on an identifiable basis. Statistical information may be compiled on an anonymous basis in group format


When completing the questionnaire please follow the instructions below

Complete all sections and answer all questions.


You must provide staff ID number in order for Medmark to assess your application and forward a result to your employer.

You may be contacted by an Occupational Health Professional if more information is required. You may also be requested to attend Medmark for a medical assessment in person.

Thank you for giving this questionnaire your time and attention.

PART B: MEDICAL QUESTIONNAIRE IN CONFIDENCE

* indicates required field
Surname: *
Previous Surname(s):
Staff ID Number: *
 
Forenames: *
Date of Birth: *
Todays Date:
 

Base: *
Name of employer: *
Expiry date of the previous medical assessment: (dd/mm/yyyy):
 
Country of birth: *
 Nationality: *
 
 
Address: *




   GP/Physician Name: *

GP Address: *





GP Tel No:
Country: *
Tel No: *
Mob No: *  
Email: *  
 
Do you currently use any medication? *
If YES, state the following
Name of medication:
Dose:
Date started (mm/yyyy):
Reason why:
 
To the best of your knowledge, have you:
    Details
1. Experienced any illness, injury or ill health? *
2. Developed any medical condition or had treatment for any illness not declared at a previous medical assessment? *
3. Noticed any deterioration of distant or close vision? For example do you have any difficulty with reading small print, seeing road signs, or driving at night time? *
4. Been prescribed glasses or contact lenses? *
5. Noticed any deterioration of hearing? *
6. Had any ear, nose, sinus or throat problems? *
If you have ticked YES for any of the questions please give details
  • •   the name the illness or injury or condition
  • •   state when symptoms first started and when the illness was diagnosed
  • •   if you attended a specialist /health care professional, give details of who you attended and if investigations/tests were carried out, give details of the results of these investigations/tests. Please state when you last visited a specialist /health care professional and if you have any further appointments
  • •   if treatment was prescribed, please give details
  • •   please indicate if you have completed your treatment and if not indicate when your treatment finishes
  • •   If you have missed any time from work as a consequence of this illness, please give details of when this was and details of the duration of time missed
  • •   If you have not made a full recovery from this illness, give details of how the illness continues to affect you
  • •   If you consider your illness is in any way work related, please give details

PART C: DECLARATION

I understand that the purpose of this Medical Questionnaire is to enable Medmark to:
  1. Establish the fitness of applicants to safely carry out duties of the intended position whilst ensuring compliance with EU OPS Regulations
  2. Assess your ability to carry out the job without any undue risk to the health and safety of yourself, your colleagues, or your passengers
  3. Form the basis of an occupational health record to be held by Medmark. This record may be referred to if the applicant is referred to Medmark at a future date.
I declare that the information I have given is true and complete to the best of my knowledge and that I have not withheld any material facts. I understand that I am responsible for the accuracy of my statement and that if I wilfully suppress any information I risk the loss of appointment. I understand that by submitting this medical assessment questionnaire I consent to Medmark Occupational Health furnishing notification concerning my fitness to work to my employer. I consent to Medmark contacting my General Practitioner or any health professional who attended me concerning anything which affects my physical or mental health.

I agree with the above declaration.

 
Medmark Dublin:
69 Lower Baggot Street
Baggot Street Bridge
Dublin 2
T: 01 6761493 / 01 6613088
F: 01 6614787 / 01 6610401
E: dublin@medmark.ie		 Medmark Galway:
Suite 16, Galway Clinic
Doughiska
Co Galway
T: 091 514440
E: galway@medmark.ie		 Medmark Limerick:
Stanford Clinic
6 Steamboat Quay
Limerick
T: 061 444888
F: 061 444889
E: limerick@medmark.ie		 Medmark Cork:
28 Penrose Wharf
Cork
T: 021 4550455
F: 021 4550454
E: cork@medmark.ie