Night Worker Health Questionnaire

Night Worker Health Questionnaire - Part 1 of 3
The purpose of this health questionnaire is to ensure that you are fit for night work. As a night worker, you are entitled under the Safety, Health and Welfare at Work (General Application) Night Work and Shift Work Regulations 2007 to a health assessment before starting night work and at regular intervals thereafter. You do not have to avail of the assessment but your employer must offer it to you
First Name
Family Name
Date
Your Email
Home Address:
Employer Name
Store Number
Employer Address:
Employer Email
Employer Phone Number
This Job Involves:
Full Time Work
Part Time Work
Night Time Work Only
Working Shifts Between Night and Day Work
The Demands of the Job Include
- Manual Handling
- Lone Working
Consent*
I consent to carry out this health assessment

Night Worker Health Questionnaire - Part 2 of 3
Initial health screening questionnaire
Please tick the boxes for any that apply to you. If any apply, you will be asked for further details on the next screen.
Do you currently suffer from any of the following?
Diabetes
Epilepsy
Disease of the heart or circulation, angina, high blood pressure
Stomach or intestinal disorder
Chronic Sleeping Difficulties
Chronic chest disorders, especially if night time symptoms are troublesome
Any medical condition requiring medication to a strict timetable
Any aspect of your health which you think may be affected by night working

Night Worker Health Questionnaire - Part 3 of 3
Do you suffer from Stomach or Intestinal Disorder?
- Yes
- No
Please give details
In submitting this health assessment questionnaire, I confirm that all information is true and to the best of my knowledge. Medwise Occupational Health will hold this information. Medwise fully comply with Data protection legislation and Medical Confidentiality Guidelines. In submitting this form I confirm that I have given explicit consent for Medwise Occupational Health services to process my personal information with respect to my night worker health assessment. Detailed clinical information will not be revealed to your employer without your consent. However we may make general recommendation based on the information you have provided.
I Agree to the above information
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Night Worker Health Questionnaire - Part 1 of 3