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045 854022
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Pre-employment Questionnaire
Step
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Company:
Department:
Personal details
Name:
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1926
1925
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1923
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1921
1920
Home address:
Telephone:
Proposed job title:
Work hours:
Shift Work
yes
no
Introduction:
In order to assess your fitness for the proposed occupation you are required to complete this confidential health questionnaire and return it to Medwise by email at info@medwise.ie . The questionnaire will be viewed by the doctor or nurse working with Medwise who may contact you to clarify medical details. You may also be required to attend for a medical examination. The employer will be advised if you are fit, unfit or fit with restrictions for the proposed post. No confidential medical details will be disclosed to any third party without your written consent. This form and any associated documents will be filed in accordance with the requirements of the Data Protection Act. Consent and declaration: I hereby declare that I voluntarily complete this questionnaire and attend MedWise for examination in order to allow assessment of my fitness to work at the proposed job. I declare that all statements made and answers to questions are true and accurate to the best of my knowledge. I authorise the company Occupational Health Physician to liaise with my doctor concerning my health. I agree to undergo medical surveillance as deemed appropriate by the company Occupational Health Physician. I understand that the answers to this form are confidential and no medical details will be disclosed to the employer without further consent from me. I consent to the information contained on this application form being processed and stored by MedWise in accordance with the requirements of the Data Protection Acts.
Consent
*
I agree to the privacy policy.
Medical history:
Name and address of General Practitioner:
Are you on any waiting lists for hospital treatment or under the care of a specialist?
yes
no
Occupational History:
Please list your jobs since leaving school:
Date 1
Occupation 1
Employer 1
Date 2
Occupation 2
Employer 2
Date 3
Occupation 2
Employer 3
Date 4
Occupation 4
Employer 4
Date 5
Occupation 5
Employer 5
Please answer the following questions, ticking yes or no as appropriate. Please give details to any questions to which you have answered yes.
Health Question
1. Are you in good health?
Yes
No
Details
2. Are you taking any medication? Please list names and doses.
Yes
No
Details
3. Have you ever had an x-ray?
Yes
No
Details
4. Have you ever had an operation?
Yes
No
Details
5. Are you allergic to any substances?
Yes
No
Details
6. Do you drink alcohol? How much per week?
Yes
No
Details
7. Have you ever been advised to reduce your alcohol intake?
Yes
No
Details
8. Have you ever been treated for an alcohol problem?
Yes
No
Details
9. Do you smoke? If Yes, how many per day?
Yes
No
Details
10. Did you ever smoke? If yes, how many and for how long?
Yes
No
Details
11. Have you taken drugs other than for medical use in the past 6 months?
Yes
No
Details
Have you ever suffered from the following:
12. Palpitation, shortness of breath, chest pain?
Yes
No
Details
13. High blood pressure, valve disease, angina, heart attack or any other disease of the heart?
Yes
No
Details
14. Persistent cough, wheeze or shortness of breath?
Yes
No
Details
15. Asthma, bronchitis, pneumonia, tuberculosis, pleurisy or other lung disease?
Yes
No
Details
16. Persistent nausea, heartburn, indigestion, stomach pains?
Yes
No
Details
17. Peptic ulcer, reflux or other gastric disorder?
Yes
No
Details
18. Recurrent diarrhoea, constipation, abdominal pain?
Yes
No
Details
19. Crohn’s disease, ulcerative colitis, other bowel disorder?
Yes
No
Details
20. Jaundice, hepatitis, gall stones or disease of the liver, pancreas, gall bladder?
Yes
No
Details
21. Diabetes, insulin dependent or otherwise?
Yes
No
Details
22. Thyroid disorder or other disease of the hormone glands?
Yes
No
Details
23. Kidney disease, bladder or urinary problem?
Yes
No
Details
24. Men: prostate disorder, testicular disease?
Yes
No
Details
25. Women: have you any ongoing gynaecological problem?
Yes
No
Details
Health Question
26. Fainting attacks, black outs, dizziness, giddiness, seizures
Yes
No
Details
27. Head injury with loss of consciousness for more than 5 minutes?
Yes
No
Details
28. Numbness, pins and needles in the hands, arms, legs or feet?
Yes
No
Details
29. Epilepsy, migraine, multiple sclerosis or other neurological disorder?
Yes
No
Details
30. Carpal tunnel syndrome, nerve entrapment or other nerve disorder?
Yes
No
Details
31. Eye problem or vision problems?
Yes
No
Details
32. Deafness?
Yes
No
Details
33. Ear problems or recurring ear infections?
Yes
No
Details
34. Hay fever or sinusitis?
Yes
No
Details
35. Skin rash, dry skin, recurrent hives or a mole that has changed?
Yes
No
Details
36. Dermatitis, eczema, psoriasis, skin infection, acne or other skin disease?
Yes
No
Details
37. Pains or swellings of the joints?
Yes
No
Details
38. Arthritis, gout, rheumatic fever or other joint problems?
Yes
No
Details
39. Bone injury or fracture?
Yes
No
Details
40. Muscle strain, sprain, or soft tissue injury?
Yes
No
Details
41. Back or neck problems (backache, injury, disc, sciatica, whiplash)?
Yes
No
Details
42. Anxiety, depression, insomnia, stress?
Yes
No
Details
43. Panic attacks, phobia?
Yes
No
Details
44. Other mental or nervous illness?
Yes
No
Details
45. Anaemia or blood disorder?
Yes
No
Details
46. Varicose veins or ankle swelling?
Yes
No
Details
47. Tumour, cyst or a mole?
Yes
No
Details
48. Have you ever had any other serious illness or injury?
Yes
No
Details
49. In the past two years, have you been absent from work due to illness or injury?
Yes
No
Details
50. Have you ever had to give up a job for health reasons?
Yes
No
Details
51. Have you worked with a substance that:
a) Gave you a rash?
b) Made you short of breath?
c) Caused back, neck or limb strain?
None
Details
52. Have you ever been exposed to the following at work or elsewhere:
a) Excessive noise?
b) Gun shot?
c) Chemicals / dust / fumes?
d) Other hazard?
None
Details
53. Have you used Personal Protective Equipment at work or elsewhere:
a) Hearing protection?
b) Respiratory protection?
c) Other equipment?
None
Details
54. Have you ever had difficulty using Personal Protective Equipment?
Yes
No
Details
55. Do you have problems with:
a) Standing, walking, bending, lifting?
b) Climbing the stairs?
c) Use of your hands, including use above shoulder height?
d) Moving your neck?
None
Details
56. Have you ever suffered with work related anxiety or stress?
Yes
No
Details
57. Do you find any of the following situations stressful:
a) Use of the telephone?
b) Dealing with the public?
c) Working under time pressure?
None
Details
Thank-you for completing this questionnaire, please return it to Medwise by email at info@medwise.ie
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
Step
1
of
4
25%
Company:
Department:
Personal details
Name:
Date
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Home address:
Telephone:
Proposed job title:
Work hours:
Shift Work
yes
no
Introduction:
In order to assess your fitness for the proposed occupation you are required to complete this confidential health questionnaire and return it to Medwise by email at info@medwise.ie . The questionnaire will be viewed by the doctor or nurse working with Medwise who may contact you to clarify medical details. You may also be required to attend for a medical examination. The employer will be advised if you are fit, unfit or fit with restrictions for the proposed post. No confidential medical details will be disclosed to any third party without your written consent. This form and any associated documents will be filed in accordance with the requirements of the Data Protection Act. Consent and declaration: I hereby declare that I voluntarily complete this questionnaire and attend MedWise for examination in order to allow assessment of my fitness to work at the proposed job. I declare that all statements made and answers to questions are true and accurate to the best of my knowledge. I authorise the company Occupational Health Physician to liaise with my doctor concerning my health. I agree to undergo medical surveillance as deemed appropriate by the company Occupational Health Physician. I understand that the answers to this form are confidential and no medical details will be disclosed to the employer without further consent from me. I consent to the information contained on this application form being processed and stored by MedWise in accordance with the requirements of the Data Protection Acts.
Consent
*
I agree to the privacy policy.
Medical history:
Name and address of General Practitioner:
Are you on any waiting lists for hospital treatment or under the care of a specialist?
yes
no
Occupational History:
Please list your jobs since leaving school:
Date 1
Occupation 1
Employer 1
Date 2
Occupation 2
Employer 2
Date 3
Occupation 2
Employer 3
Date 4
Occupation 4
Employer 4
Date 5
Occupation 5
Employer 5
Please answer the following questions, ticking yes or no as appropriate. Please give details to any questions to which you have answered yes.
Health Question
1. Are you in good health?
Yes
No
Details
2. Are you taking any medication? Please list names and doses.
Yes
No
Details
3. Have you ever had an x-ray?
Yes
No
Details
4. Have you ever had an operation?
Yes
No
Details
5. Are you allergic to any substances?
Yes
No
Details
6. Do you drink alcohol? How much per week?
Yes
No
Details
7. Have you ever been advised to reduce your alcohol intake?
Yes
No
Details
8. Have you ever been treated for an alcohol problem?
Yes
No
Details
9. Do you smoke? If Yes, how many per day?
Yes
No
Details
10. Did you ever smoke? If yes, how many and for how long?
Yes
No
Details
11. Have you taken drugs other than for medical use in the past 6 months?
Yes
No
Details
Have you ever suffered from the following:
12. Palpitation, shortness of breath, chest pain?
Yes
No
Details
13. High blood pressure, valve disease, angina, heart attack or any other disease of the heart?
Yes
No
Details
14. Persistent cough, wheeze or shortness of breath?
Yes
No
Details
15. Asthma, bronchitis, pneumonia, tuberculosis, pleurisy or other lung disease?
Yes
No
Details
16. Persistent nausea, heartburn, indigestion, stomach pains?
Yes
No
Details
17. Peptic ulcer, reflux or other gastric disorder?
Yes
No
Details
18. Recurrent diarrhoea, constipation, abdominal pain?
Yes
No
Details
19. Crohn’s disease, ulcerative colitis, other bowel disorder?
Yes
No
Details
20. Jaundice, hepatitis, gall stones or disease of the liver, pancreas, gall bladder?
Yes
No
Details
21. Diabetes, insulin dependent or otherwise?
Yes
No
Details
22. Thyroid disorder or other disease of the hormone glands?
Yes
No
Details
23. Kidney disease, bladder or urinary problem?
Yes
No
Details
24. Men: prostate disorder, testicular disease?
Yes
No
Details
25. Women: have you any ongoing gynaecological problem?
Yes
No
Details
Health Question
26. Fainting attacks, black outs, dizziness, giddiness, seizures
Yes
No
Details
27. Head injury with loss of consciousness for more than 5 minutes?
Yes
No
Details
28. Numbness, pins and needles in the hands, arms, legs or feet?
Yes
No
Details
29. Epilepsy, migraine, multiple sclerosis or other neurological disorder?
Yes
No
Details
30. Carpal tunnel syndrome, nerve entrapment or other nerve disorder?
Yes
No
Details
31. Eye problem or vision problems?
Yes
No
Details
32. Deafness?
Yes
No
Details
33. Ear problems or recurring ear infections?
Yes
No
Details
34. Hay fever or sinusitis?
Yes
No
Details
35. Skin rash, dry skin, recurrent hives or a mole that has changed?
Yes
No
Details
36. Dermatitis, eczema, psoriasis, skin infection, acne or other skin disease?
Yes
No
Details
37. Pains or swellings of the joints?
Yes
No
Details
38. Arthritis, gout, rheumatic fever or other joint problems?
Yes
No
Details
39. Bone injury or fracture?
Yes
No
Details
40. Muscle strain, sprain, or soft tissue injury?
Yes
No
Details
41. Back or neck problems (backache, injury, disc, sciatica, whiplash)?
Yes
No
Details
42. Anxiety, depression, insomnia, stress?
Yes
No
Details
43. Panic attacks, phobia?
Yes
No
Details
44. Other mental or nervous illness?
Yes
No
Details
45. Anaemia or blood disorder?
Yes
No
Details
46. Varicose veins or ankle swelling?
Yes
No
Details
47. Tumour, cyst or a mole?
Yes
No
Details
48. Have you ever had any other serious illness or injury?
Yes
No
Details
49. In the past two years, have you been absent from work due to illness or injury?
Yes
No
Details
50. Have you ever had to give up a job for health reasons?
Yes
No
Details
51. Have you worked with a substance that:
a) Gave you a rash?
b) Made you short of breath?
c) Caused back, neck or limb strain?
None
Details
52. Have you ever been exposed to the following at work or elsewhere:
a) Excessive noise?
b) Gun shot?
c) Chemicals / dust / fumes?
d) Other hazard?
None
Details
53. Have you used Personal Protective Equipment at work or elsewhere:
a) Hearing protection?
b) Respiratory protection?
c) Other equipment?
None
Details
54. Have you ever had difficulty using Personal Protective Equipment?
Yes
No
Details
55. Do you have problems with:
a) Standing, walking, bending, lifting?
b) Climbing the stairs?
c) Use of your hands, including use above shoulder height?
d) Moving your neck?
None
Details
56. Have you ever suffered with work related anxiety or stress?
Yes
No
Details
57. Do you find any of the following situations stressful:
a) Use of the telephone?
b) Dealing with the public?
c) Working under time pressure?
None
Details
Thank-you for completing this questionnaire, please return it to Medwise by email at info@medwise.ie
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
MedWise occupational health physicians provide expert advice to HR, Health and Safety and Management.
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Unit 32, Naas Town Centre,
Dublin Road, Naas,
Co. Kildare
W91 R230
Swords Clinic
First Floor, Chamber Building
North Street, Swords
Co. Dublin
K67 A3H7