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Pre-Employment Questionnaire for Food Handlers

Introduction:
The purpose of the pre-employment medical questionnaire is to enable Medmark:

  1. Determine the fitness of applicants to safely carry out duties of the intended position whilst ensuring compliance with Employment Equality legislation.
  2. Screen for underlying medical disorders so that the employers can meet their responsibilities under Health and Safety and Disability Legislation.
  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 service for the named company. 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.

If you answer 'YES' to any of the questions under the heading 'HAVE YOU EVER HAD OR DO YOU NOW SUFFER FROM', then provide the following information on the form:

  • The name of the illness.
  • 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/college 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.

You may be contacted by the Occupational Health Physician if you do not complete the questionnaire in sufficient detail, and if more information is required. This may delay your application. You may also be requested to attend Medmark for a pre-employment assessment in person.

Thank you for giving this questionnaire your time and attention.

 

Prospective Employer: *
       
               
First Name: *
Last Name: *
  Date of Birth: *
Todays Date:
               
Tel No. (H): *
    
Tel No. (W): *
Mobile: *
Email: *
Address: *




Name and Address of Family Doctor: *




               
Job Description:*
   
Please complete the following health questionnaire: Where a "yes" is provided in answer to any of the following questions, please provide some details if possible.
     
1. Do you smoke
If yes, please quantify your daily intake.
2. Do you drink alcohol?
If yes, what is your weekly consumption of alcohol?
3. Has your alcohol intake changed in the last five years?
If so, please give details.
4. Are you currently using or have you used in the last 5 years any drugs of abuse? e.g. cocaine, opiates (i.e. heroin/methadone etc.) ecstacy, amphetamins, marijuana etc.
5. Have you ever been treated or had counselling for alcohol or drug abuse? If so, please give details.
6. Have you ever been denied a job on health grounds?
7. Have you ever been denied life or permanent health insurance on health grounds?
8. Have you ever had to pay an increased premium for any form of insurance on health grounds?
9. Have you ever applied for or received compensation for a disease, accident or injury?
10. Are you attending or have you attended a doctor or hospital for medical care or treatment in the last five years?
11. Are on on a waiting list for hospital treatment? If so, please indicate the nature of the problem.
12. Are you currently taking any medication? If so, please indicate why and the name of the medication.
13. How often have you visited your doctor in the last year? Please give details.
14. Have you ever been absent from work due to illness/injury for a continuous period in excess of two weeks?
         
Have you ever had or do you suffer from:    
15. Lung/chest problems?
e.g. asthma, TB, pneumonia, bronchitis
16. Heart problems or circulatory disorders?
e.g. heart murmur, heart attack, high blood pressure, curculatory problems
17. Stomach/bowel/liver/gallbladder or pancreatic problems?
18. Kidney disorder?
e.g. Kidney stones/infections or kidney failure
19. Glandular problems?
e.g. diabetes or thyroid problem
20. Disorders of the nervous system?
e.g. Fits, blackouts, migraine, epilepsy, stroke
21. Psychiatric or mental health problems?
e.g. anxiety, depression, nervous breakdown, anorexia or attendance with a psychiatrist
22. Have you ever suffered from a fatigue syndrome?
e.g. post viral fatigue, M.E., burnout etc
23. Eyes, ears, nose or throat problems?
24. Sexually transmitted or tropical diseases?
25. Skin problems?
e.g. Moles, eczema, dermatitis, psoriasis
26. Tumors - benign or malignant?
27. Have you ever had an operation?
28. Have you any allergies?
29. Have you ever had any gynaecological problems?
   
30. Any other accidents, illness or injuries?
31. Neck of back trouble?
e.g. muscular problems, whiplash, disc prolapse
32. Arthritis, joint problems, gout?
33. Work related upper limb disorder (WRULD)?
or
Repetitive strain injury (RSI), tendonitis?
         
Do you have any problems or have you had any problems in the past with
34. Standing 37. Bending 40. Working at heights
35. Walking 38. Moving your neck or back 41. Climbing stairs
36. Lifting 39. Using your hands or elbows    
    39b.Have you ever attended a manual handling training course?    
 
OCCUPATIONAL HISTORY - Please provide some detail concerning previous jobs in which you have worked.
DATE BRIEF JOB DESCRIPTION INDICATE WHETHER ANY EXPOSURE TO CHEMICALS, DUST OR NOISE
                 
Please tick yes/no in response to the following questions. Please give details in the event of a "yes" answer in the space provided.
Have you had or do you suffer from: Details
42. Difficulty hearing?
43. This feeling that people were not speaking clearly?
44. Difficulty hearing people in a crowded room?
45. Buzzing noises (tinnitus) in your ears?
46. Surgery for any ear disorder?
47. Family history of deafness?
48. A head injury or blows to the head/ears?
49. Have you been exposed to a noisy environment in the last 48 hours? i.e. disco, noisy work environment, etc.
50. Have you ever been in military service or worked for the FCA?
51. Have you ever had an audiogram (hearing test)?
52. Have you ever worn hearing protection at work?
53. Have you ever had or do you have noisy hobbies? e.g. hunting/shooting, auto racing, loud music, etc.
54. Are you taking or have you ever taken drugs for malaria/kidney disease/meningitis or TB?
Have you ever had:
55. Typhoid fever?
56. Paratyphoid fever?
57. Ear trouble or a running ear?
58. Frequent cough and phlegm?
59. Recurring skin trouble?
60. A food borne illness?
At present are you suffering from:
61. Ear trouble or running ear?
62. Cough with phlegm?
63. Acne, boils, styes or septic fingers?
64. Diarrhoea, nausea, abdominal pain or fever?
65. Gum disease or tooth decay?
66. Skin trouble affecting hands/arms/face?
67. Do you bite your nails?
68. When did you last visit your dentist? (dd/mm/yyyy)
69. Have you suffered from food poisoning symptoms in the last 12 months?
70. Have you been abroad in the last 3 weeks?
 

 

DECLARATION

I declare that the information I have given it 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 statements and that if I wilfully suppress any information that I risk the loss of the appointment.

I understand that the purpose of this pre-employment medical is to establish the following:

* that I am fit for the job;
* that I can carry out the job without any undue risk to the health and safety of myself or others at work;
* that my employer will have reasonable expectation that I will provide regular attendance at work until retirement.

I consent to the occupational physician/nurse furnishing the report to the company from which I'm seeking employment. I understand that relevant details of my personal or medical history will not be disclosed to the personnel department without my consent. I understand that the report's will concern my fitness for work and may contain suggested restrictions/alterations to ensure the health and safety of myself and others at work.

By submitting this document to Medmark I understand, accept and consent to all of the above.

I accept that if I do not understand and accept and consent to all of the above that I will not forward this document to Medmark.

 

 

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