Pre-employment Questionnaire

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

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Pre-employment Questionnaire

Step 1 of 4

Personal details

Introduction:

Medical history:

Occupational History:

Health Question

Have you ever suffered from the following:

Health Question

Step 1 of 4

Personal details

Introduction:

Medical history:

Occupational History:

Health Question

Have you ever suffered from the following:

Health Question