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Pre-Employment Health Questionnaire

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.

 

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




Name and Address of Family Doctor: *




               
Prospective Hospital/Employer Name: *
               
Title of proposed job/department: *
   
   
Have you been resident in Ireland for the last 5 years?
If not, please state where you have lived.
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?
1 pint beer
Spirit
Glass wine
= 2 units
= 1½ units
= 1 unit
   
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 had to give up a job for health reasons or injury?
8. Have you ever been denied life or permanent health 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 you currently taking any medication? If so, please give name of medication and indicate the nature of the problem.
12. How often have you visited your doctor in the last year? Please give details.
13. 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:    
14. Lung/chest problems (e.g. asthma, TB, pneumonia, bronchitis) or have you been in contact with TB within the last 2 years?
15. MRSA - If yes, have you completed an eradication protocol and had 3 clear MRSA swabs following treatment?
16. Heart problems or coronary disorders e.g. heart murmur, heart attack, high blood pressure, anaemia, circulatory problems (i.e. varicose veins/ankle swelling)
17. Stomach, bowel, jaundice, hepatitis or any other liver disease, gallbladder or pancreatic problems?
18. Prostate problems or kidney disorders e.g. kidney stones, infections or kidney failure
19. Glandular problems e.g. diabetes or thyroid problems
20. Disorders of the nervous system e.g. fits, blackouts, migraine, recurring headaches, epilepsy, stroke
21. Psychiatric or mental health system e.g. anxiety, depression, nervous breakdown, eating disorders, work stress or attendance with a psychiatrist
22. Specific learning difficulties e.g. dyspraxia, dyslexia
23. Fatigue syndrome e.g. post viral fatigue, M.E., burnout etc
24. Eye problems e.g. colour blindness, lazy eye, glaucoma etc
25. Ear, nose or throat problems, hearing or speech impairment
26. Sexually transmitted or tropical diseases e.g. syphilis or hepatitis B
27. Skin problems?
e.g. Moles, eczema, dermatitis, psoriasis
28. Tumors - benign or malignant?
29. Have you ever had an operation?
30. Allergies e.g. to drugs, food, chemicals or latex
31. Admission to hospital because of an allergic reaction e.g. anaphylaxis
32. Back or neck trouble e.g. backache, injury, disc prolapse, disc/back surgery, whiplash, occupational back injury
33. Lost time at work due to backache?
34. Arthritis, joint problems, gout?
35. Work related upper limb disorder (WRULD) or repetitive strain injury (RSI) or tendonitis
36. Have you ever had any gynaecological problems that may interfere with your ability to work e.g. uterine prolapse?
   
37. Any other accidents, illness or injuries?
         
Do you have any problems or have you had any problems in the past with
38. Standing 41. Bending 44. Working at heights
39. Walking 42. Moving your neck or back 45. Climbing stairs
40. Lifting 43. Using your hands or elbows      
 
 
46. Have you ever attended a manual handling training course?    
Date course completed    
 
OCCUPATIONAL HISTORY
PLEASE LIST YOUR JOBS, STARTING WITH THE LAST ONE AND WORKING BACK TO SCHOOL.
(INCLUDE PART-TIME JOBS HELD FOR OVER 3 MONTHS.)
Dates from - to Workplace Job description
                 
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: IF "YES" PLEASE GIVE DETAILS
47. Have you ever experienced any health effects or injury that you associated with workplace exposure, i.e. needle stick/ inoculation injury?
48. Did you ever work with a substance that gave you a rash, made you short of breath, cough or wheeze or caused strain in your limbs or back?
49. Have you ever tested positive for hepatitis B, C, HIV or any other blood borne virus?
50. Have you ever worked for a year or more in a dusty job?
51. Have you ever been exposed to gas or chemical fumes at work?
52. Have you ever worked for a year or more in a noisy job?
53. Do you have any hobbies that may involve exposure to chemicals or other hazards?
54. Will your new position with this employer require you to carry out Exposure Prone Procedures?
click for more info »
What are exposure prone procedures?
Exposure prone procedures (EPPs) are those where there is a risk that injury to the worker may result in exposure of the patient's open tissues to the blood of the worker. These procedures include those where the worker's gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times.

If you are required to perform exposure prone procedure in your work what requirements will you have to fulfill in addition to the pre-employment assessment?
You will be required to submit the following identity validated blood sample (IVS) results: anti hepatitis C antibody; hepatitis B surface antigen; and anti hepatitis B surface antibody titer.

What is an identity validated sample?
It is a blood sample taken in the following circumstances:
The health-care worker should show photographic proof of identity (e.g. hospital ID badge, driver's licence etc.) at the time of sampling. The sample should be taken in the occupational health department (OHD). The sample should be transported to the laboratory in the normal way and not by the health-care worker. Upon receipt of results from the laboratory, the OHD must confirm that sample was taken in the OHD. In Ireland the approved laboratory for such samples is the National Virus Reference Laboratory at UCD, Belfield. Samples which are recognised as identity validated should be stamped and signed as such by a physician or nurse in the OHD that took the sample.

IMMUNISATION/VACCINATION
55. Are you aware of having received B.C.G. vaccination as a child Date:
56. On examination of (L) upper arm is there a scar present Date:
57. Measles/Mumps/Rubella Status Date:
58. Chickenpox (Varicella) Date:
59. Hep. B primary course of 3 injections Date:
 

 

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.

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