Health Pre-Assesment Form

Please note that all information in this questionnaire is strictly private and confidential.
1. Applicant's Medical Profile
Do you suffer from:
*Bronchitis, wheezing or other lung disorders Yes No
*Allergies, hay fever or sinus troubles Yes No
*Skin rashes, eczema, dermatitis or psoriasis Yes No
*Varicose veins, hernia Yes No
*Asthma; epilepsy Yes No
*Mental illness, nervous disorders; depression Yes No
*Diabetes Yes No
*Do you have any conditions including shoulder, neck or joint injuries, strains, arthritis, gout or disorders which restrict your ability to lift and carry? Yes No
*Any eye or ear disorders that could affect you carrying out the duties you are applying for? Yes No
*Any other medical or surgical problems that could prevent you from performing the duties you are applying for? Yes No
*Are you currently being treated by any doctor for any illness? Yes No
*If you have answered YES to any of these questions, please give details:
*Do you suffer from back pain or had any back problem which restrict you from lifting, or carrying any object? Yes No
If you have answered YES, please answer the following:
*What was the location and type of pain?

  
*How long did you have the pain?
*What was the original cause of it?
*What movement aggravated it?
*How long since you experienced these symptoms?
*Have you ever had an injury at work? Yes No
If you have answered YES, please answer the following:
*When and how did the injury occur?
*What injury did you sustain?
*How much time off work did you require?
*Did you successfully complete a rehabilitation programme? Yes No
2. Applicant's Medical History
*Do you have any conditions which prevent or limit you doing the work for which you have applied? (For example back or other muscular injury that you have already obtained from previous activities? Yes No
*If you have answered YES, please provide further details:
3. Declaration

I certify the above statements are true and I authorise my private doctor to supply any additional information that may be required in connection with any sickness or accidents for which he/she has trated me.

I am aware that if any statements above are purposely misleading that this may render my workers compensation cover invalid and lead to the immediate termination of my employemnt.

* I Agree.

Section 79 of the Workers Compensation and Assistance Act 1981 gives the Workers Compensation Board discretion to refuse to award compensation which would otherwise by payable where it has proved that the worker has at the time of seeking or entering employment, wilfully or falsely represented him/herself as not having previously suffered from the disability, the subject of the claim for compensation.

* Required
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