Health Check Form

Applicant First Name
Applicant Last Name
Job Applying For
Date
What is your approximate Height?*
What is your approximate Weight?*
The majority our clients have non-smoking policies, which include only being able to smoke during designated breaks, and in designated areas, do you have any issues with going for a period up to 4 hours without a cigarette*
- Yes
- No
Most of our client have a random drug and alcohol policy, are you willing to submit to a random drug and alcohol testing?*
- Yes
- No
Are you currently taking any medication, or have you taken any medication for more than two weeks within the past 2 years?*
- Yes
- No
*
Name of Medication Condition Period taken
Do you have difficulty sitting or standing for a minimum of 8 hours per day?*
- Yes
- No
Do you have difficulty steadily walking 4 kilometres in an hour?*
- Yes
- No
Have you ever suffered injuries as the result of a car accident?*
- Yes
- No
Type of injury?*
Year injury happened.*
Is there any on going medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Are there other car accident injuries?*
- Yes
- No
Type of injury?*
Year injury happened.*
Is there any on going medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Are there any other car accident injuries?*
- Yes
- No
Type of injury?*
Year injury happened.*
Is there any on going medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Have you ever suffered injuries as the result of a workplace injury?*
- Yes
- No
Type of injury?*
Year injury happened.*
How much time off was required?*
Is there any ongoing medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Are there other workplace injuries?*
- Yes
- No
Type of injury?*
Year injury happened.*
How much time off was required?*
Is there any ongoing medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Are there any other workplace injuries?*
- Yes
- No
Type of injury?*
Year injury happened.*
How much time off was required?*
Is there any ongoing medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Have you ever suffered an injury whilst playing sport?*
- Yes
- No
Type of injury?*
Year injury happened.*
Is there any ongoing medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Are there other sports injuries?*
- Yes
- No
Type of injury?*
Year injury happened.*
Is there any ongoing medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Are there any other sports injuries?*
- Yes
- No
Type of injury?*
Year injury happened.*
Is there any ongoing medical treatment associated with this injury?*
Are there any restrictions associated with this injury?*
Have you had any operations?*
- Yes
- No
Type of operation?
Is there any ongoing medical treatment associated with this operation?*
- Yes
- No
Are there any restrictions associated with this operation?*
- Yes
- No
Are there other operations?*
- Yes
- No
Type of operation?
Is there any ongoing medical treatment associated with this operation?*
- Yes
- No
Are there any restrictions associated with this operation?*
- Yes
- No
Are there any other operations?*
- Yes
- No
Type of operation?
Is there any ongoing medical treatment associated with this operation?*
- Yes
- No
Are there any restrictions associated with this operation?*
- Yes
- No
Have you ever undertaken a rehabilitation program?*
- Yes
- No
*
Reason Work Related (Yes/No) Rehab from Rehab to
Do you currently have any work restrictions issued by a medical practitioner?*
- Yes
- No
Specify restrictions:*
Do you have any of the following conditions?
Arthritis, joint pain or swelling*
- Yes
- No
Numb fingers or hands*
- Yes
- No
Tennis elbow or golfers’ elbow*
- Yes
- No
Tendonitis*
- Yes
- No
Wrist pain, injury or ganglion*
- Yes
- No
Repetitive strain (RSI) or overuse injury or pain*
- Yes
- No
Knee injury, swelling or pain*
- Yes
- No
Back pain or disc problem*
- Yes
- No
Sciatica or leg pain*
- Yes
- No
Neck pain, stiff neck or whiplash*
- Yes
- No
Shoulder pain, tendonitis or frozen shoulder*
- Yes
- No
Hip pain*
- Yes
- No
Treatment on back or neck*
- Yes
- No
Back or neck X-Ray or scan*
- Yes
- No
Chronic Fatigue (lasting more than six weeks)*
- Yes
- No
Depression*
- Yes
- No
Stress at work*
- Yes
- No
Anxiety, nervous illness or breakdown*
- Yes
- No
Mental illness such as schizophrenia or bipolar disorder*
- Yes
- No
Conflict at work that required medical treatment or counselling*
- Yes
- No
Bowel or kidney problem*
- Yes
- No
Frequent heartburn, ulcers or pancreatitis*
- Yes
- No
Hypertension (high blood pressure)*
- Yes
- No
Heart attack or angina*
- Yes
- No
Chest Pain*
- Yes
- No
Stroke or temporary stroke attacks*
- Yes
- No
Epilepsy, fits or blackouts*
- Yes
- No
Dizzy spells, fainting, attacks or unconsciousness*
- Yes
- No
Migraines or regular headaches*
- Yes
- No
Haemorrhoids (piles)*
- Yes
- No
Blood clots or varicose veins*
- Yes
- No
Allergy to grass or pollens*
- Yes
- No
Asthma*
- Yes
- No
Tuberculosis, emphysema or bouts of bronchitis*
- Yes
- No
Shortness of breath or persistent cough*
- Yes
- No
Hernia in the groin or anywhere*
- Yes
- No
Hepatitis or liver problems*
- Yes
- No
Kidney, bladder or prostrate problems*
- Yes
- No
Cancer or tumour of any type*
- Yes
- No
Diabetes or thyroid problem*
- Yes
- No
Skin rashes, dermatitis or eczema*
- Yes
- No
Psoriasis or other skin problems*
- Yes
- No
Allergy to chemicals or contact with materials*
- Yes
- No
Any other allergies*
- Yes
- No
In the past 4 weeks, about how often did you feel tired out for no good reason?*
- None of the time
- A little of the time
- Some of the time
- Most of the time
- All of the time
In the past 4 weeks, about how often did you feel so nervous that nothing would calm you down?*
- None of the time
- A little of the time
- Some of the time
- Most of the time
- All of the time
In the past 4 weeks, about how often did you feel restless or fidgety?*
- None of the time
- A little of the time
- Some of the time
- Most of the time
- All of the time
In the past 4 weeks, about how often did you feel so restless you could not sit still?*
- None of the time
- A little of the time
- Some of the time
- Most of the time
- All of the time
In the past 4 weeks, about how often did you feel depressed?*
- None of the time
- A little of the time
- Some of the time
- Most of the time
- All of the time
In the past 4 weeks, about how often did you feel that everything was an effort*
- None of the time
- A little of the time
- Some of the time
- Most of the time
- All of the time
In the past 4 weeks, about how often did you feel worthless?*
- None of the time
- A little of the time
- Some of the time
- Most of the time
- All of the time
Allergy to rubber, rubber bands or string*
- Yes
- No
Details*
Any skin condition affecting the hands or feet*
- Yes
- No
Details*
Tinnitus or ringing in the ears*
- Yes
- No
Details*
Hearing Loss or difficulties*
- Yes
- No
Details*
Eye Problems (other than those resulting in the need for glasses)*
- Yes
- No
Details*
Feet problems or ankle problems, or feet pain when standing or walking*
- Yes
- No
Details*
Do you have any medical conditions that are not mentioned in the above that you think may result in you being unable to healthy and safely perform duties and tasks that involve manual labouring duties?*
- Yes
- No
Details*

Name of Medication	Condition	Period taken

Type of operation?

Type of operation?

Type of operation?

Health Check Form

Do you have any of the following conditions?