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Food handler hygiene form

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Applicant / Employee information
Employee Name:*
Date of Birth:*
Employer:*

Applicant / Employee Consent
I consent to attend for hygiene screening. I understand that this is to ensure that I am fit to work as a food handler. I consent for a report of this assessment to be issued to my employer. I agree to follow any recommendations given by the health professional. The answers I give are true and accurate to the best of my knowledge.
Consent*
I consent to attend for hygiene screening
Date:*

Medical history - Current
Please answer the following questions, tick yes or no as appropriate, and provide details to any Yes answers.
Are you suffering now, or within the last seven days, from any of the following:
(a) Diarrhea, Dysentry, Typhoid?*
- Yes
- No
Details
(b) Vomiting?*
- Yes
- No
Details
(c) Jaundice, Hepatitis A and/or E?*
- Yes
- No
Details
(d) Gum disease / tooth decay?*
- Yes
- No
Details
(e) Do you bite your nails?*
- Yes
- No
Details
(f) A skin infection, ulcer or sores which are oozing, weeping or blistering, affecting the hands, arms, face, neck or scalp?*
- Yes
- No
Details
(g) Skin condition (eg eczema,psoriasis, impetigo) affecting the hands, arms, face, neck or scalp?*
- Yes
- No
Details
(h) Discharge from eyes, ears, nose, mouth or gums?*
- Yes
- No
Details
(i) Sore throat with fever?*
- Yes
- No
Details
(j) Respiratory disease, such as Tuberculosis (TB)?*
- Yes
- No
Details
Medical history - Ongoing
Do you suffer from:
(l) A recurring bowel problem?*
- Yes
- No
Details
(l) Recurring skin condition (eg eczema or psoriasis)?*
- Yes
- No
Details
Medical history - Past
(m) Have you ever been diagnosed as being ill with, or to be a carrier of Typhoid or Paratyphoid, Tuberculosis (TB), Hepatitis A or E or dysentry?*
- Yes
- No
Details
(n) In the last 21 days have you been in contact with anyone, at home or abroad, who may have been suffering from Typhoid or Paratyphoid?*
- Yes
- No
Details
(o) In the last 10 days have you been in contact with anyone in your household who may have been suffering from E. coli (VTEC) infection?*
- Yes
- No
Details
(p) When did you last visit the dentist?*
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