Pre-Placement Health Questionnaire"*" indicates required fieldsYour Name:*New Employer Company Name:*Job Role:*Location:*IMPORTANTNo part of this form may be reproduced or amended without the prior permission in writing of Miller Health Management, Prama House, 267 Banbury Road, Oxford, OX2 7HT© 2022 copyright Miller Health ManagementIntroductionPlease read the following notes before completing the questionnairePurpose of QuestionnaireOnce a job has been offered this questionnaire is to ensure that the work you will be doing will not pose an unreasonable risk to your health and to ensure you are fit for the job. Your prospective employer will be notified of your fitness to carry out the duties of the post offered and any particular adjustments that may be required to enable you to carry out your duties effectively.Additional informationShould the occupational health adviser require any additional information, he/she will contact you directly. In all cases your prospective employer reserves the right to invite you to attend a pre-employment medical examination if required.ConfidentialityAll information provided by you in the completion of this questionnaire will be treated in the strictest of confidence by the occupational health adviser. Please answer all questions fully and accurately so that your fitness for employment can be assessed objectively.DisclosureIt is important for both your own safety and the safe and efficient operation of the business that your answers to all questions are truthful and complete. Please note that failure to disclose all relevant information covering your health could result in the termination of your employment.Section 1 – Personal Details (please complete in block capitals)Dr/Mr/Mrs/Miss/Ms* Dr Mr Mrs Miss MsSurname:*Forenames:*Known as:*Home Address:*Home Telephone number (incl. local code)Email address:* Mobile number:*Date of Birth:* MM slash DD slash YYYY Weight:*Height:*Name, and address of your General Practitioner:Telephone Number of your GP’s Practice/Surgery (incl. local code):Section 2 – Job Applied ForJob Title:*Work location/base:*Number of hours to be worked per week:*Shifts?* Yes NoDoes this include night shift?* Yes NoPhysical Demands of the job – please tick the appropriate box Heavy lifting >15kg Bending Keyboard User Mod lifting <15kg Twisting VDU Light lifting <5kg Stooping Clerical work Repetitive lifting Squatting Chemical contact Prolonged standing Kneeling Paint Stretching up Walking Solvents Repetitive arm movement Driving Others (specify) Mentally/emotionally demandingSECTION 3 – Occupational History (Please note example below)Please list all the jobs you have had since leaving school. Include all information about any special hazards or health risks to which you were exposed to in these jobs, and list any health screening that was carried out. Continue on a separate sheet if necessary.EXAMPLECompany: ABC AccountantsFrom: Jan 2001To: Jun 2004Job Title: Personal AssistantHealth Hazards/Health Screening: Working with Display Screen Equipment [DSE]. A DSE risk assessment was carried out to identify any potential risks and to ensure that my workstation was appropriately set up. I was also provided with guidance on good working practices. Reason For Leaving: Career Development Please answer N/A if this is your first jobCompany:*From:* MM slash DD slash YYYY To:* MM slash DD slash YYYY Job Title:*Health Hazards/Health Screening:*Reason For Leaving:*Company:From: MM slash DD slash YYYY To: MM slash DD slash YYYY Job Title:Health Hazards/Health Screening:Reason For Leaving:Company:From: MM slash DD slash YYYY To: MM slash DD slash YYYY Job Title:Health Hazards/Health Screening:Reason For Leaving:Company:From: MM slash DD slash YYYY To: MM slash DD slash YYYY Job Title:Health Hazards/Health Screening:Reason For Leaving:Company:From: MM slash DD slash YYYY To: MM slash DD slash YYYY Job Title:Health Hazards/Health Screening:Reason For Leaving:Instructions for following sections:Answer the following questions by ticking yes or no. Where your answer is yes, please provide further details and dates (where appropriate) in the space provided. If you wish to add any additional medical information which you feel is relevant, space is provided at the end of the questionnaire.Section 4 – Personal Activities/HobbiesActivity/Hobby1 Do you smoke, or have you smoked in the past?* Yes NoDetails*2 Do you consume alcohol? If yes, what is your average weekly consumption in units? (See definition below)* Yes NoDetails*3 Do you exercise on a regular basis?* Yes NoDetails*4 Do any of your hobbies/pursuits have health risks (e.g. noise, fumes, dust, chemicals, vibration, and repetitive movement of the hands or fingers?* Yes NoDetails*Definition of one unit of alcohol: Half a pint of ordinary strength beer, lager or cider, OR one small glass of wine OR one single measure of spirits.Section 5 – Health RecordInjury/Illness1 Have you ever been retired from or left a job on the grounds of ill-health?* Yes NoDetails*2 Have you ever suffered from, or had a work-related disease or accident?* Yes NoDetails*3 Are you currently receiving any treatment, injections, medicine, pills/tablets from a doctor?* Yes NoDetails*4 Do you take any regular non-prescribed medication?* Yes NoDetails*5 Have you ever had any previous fractures of bones or dislocation of joints?* Yes NoDetails*6 Have you ever been treated in hospital as an out-patient, in-patient or in an Accident and Emergency Department?* Yes NoDetails*7 In the last two years, have you been absent from your place of work, study or other activities due to illness or injury?* Yes NoDetails*Section 6 – Medical History Do you have, or have you ever suffered from any of the following conditions. If yes, please give details. Continue on a separate sheet if necessary.1 Severe and prolonged headaches/migraines?* Yes NoDetails*2 Eye disease or visual problems?* Yes NoDetails*3 Do you wear spectacles or contact lenses? Please state which you use and date of last optician check.* Yes NoDetails*4 Any ear trouble, disease or hearing problems?* Yes NoDetails*5 Do you wear a hearing aid?* Yes NoDetails*6 Epilepsy, fainting attacks, blackouts or attacks of giddiness or dizziness?* Yes NoDetails*7 Do you have any difficulties sleeping, or have you ever been diagnosed or investigated for a sleep disorder (e.g. sleep apnoea)?* Yes NoDetails*8 Chest diseases: Bronchitis, Pneumonia, Pleurisy or Asthma?* Yes NoDetails*9 Raised blood pressure?* Yes NoDetails*10 Heart or Circulatory problems?* Yes NoDetails*11 Rheumatism, Arthritis or joint problems?* Yes NoDetails*12 Any deformity, injury or medical condition of the upper limbs?* Yes NoDetails*13 Any recurrent upper limb problems, eg. Tendonitis, Tenosynovitis, or Carpal Tunnel Syndrome?* Yes NoDetails*14 Any injury or medical condition (including pain) of the neck, spine or lower back?* Yes NoDetails*15 Any deformity, injury or medical condition of the hips or lower limbs?* Yes NoDetails*16 Any medical condition involving muscles, ligaments, tendons, joints or structures related to the above not mentioned previously?* Yes NoDetails*17 Have you had any treatment from a physiotherapist or osteopath in the past?* Yes NoDetails*18 Psychiatric illness or nervous trouble, depression, anxiety or panic attacks?* Yes NoDetails and Dates*19 Any eating problems or major fluctuations in weight?* Yes NoDetails and Dates*20 Blood disorders, Anaemia, Jaundice, Hepatitis?* Yes NoDetails and Dates*21 Disorders of the Bladder or Kidney?* Yes NoDetails and Dates*22 Diabetes or Thyroid problems* Yes NoDetails and Dates*23 Gastric or bowel problems, e.g. ulcer, hiatus hernia, colitis, irritable bowel syndrome?* Yes NoDetails and Dates*24 Hernia or other problems with abdominal wall muscles?* Yes NoDetails and Dates*25 Any skin problems e.g. dermatitis, eczema or psoriasis?* Yes NoDetails and Dates*26 Do you suffer from any allergies?* Yes NoDetails and Dates*27 Any other illness or injury which has required medical attention?* Yes NoDetails and Dates*28. Have you ever been diagnosed with any neurodivergence such as ADHD, Autism, Spectrum Condition, Dyslexia, Dyspraxia (DCD) or Dyscalculia?* Yes NoIf so, when was this diagnosis made?*29. Have you ever received adjustments during school, university, or work which supported you in completing tasks, such as extra time in exams, additional classroom support, or a scribe or note-taker for your learning?* Yes NoIf yes, please give details:*If your answer to question 29 was ‘yes’ what facilities, adjustments or equipment (if any) would enable you to perform the duties of the post more effectively? Please use a separate sheet if necessarySection 7 – Functional Abilities Do you have difficulties with any of the following activities: Activity1 Standing* Yes NoDetails*2 Sitting* Yes NoDetails*3 Walking* Yes NoDetails*4 Climbing stairs* Yes NoDetails*5 Lifting* Yes NoDetails*6 Use of hands* Yes NoDetails*7 Driving* Yes NoDetails*7a If you are required to drive a car on company business are there any reasons why you may not be able to do so?* Yes NoDetails*SECTION 8 – Using a keyboard Keyboard Skills1 Have you had any keyboard training? Yes NoDetails2 When you use a keyboard do you use all of your fingers? Yes NoDetailsSection 9 – Additional Medical Information (Please list any further details of your medical history not covered so far, using additional pages if required). Please note you must disclose ALL information concerning your medical circumstances.Additional Medical InformationDeclaration: I declare that all of the statements and information I have included in this questionnaire are true and accurate to the best of my knowledge. I understand that making a false declaration may lead to serious disciplinary action including dismissal.Signature*Date:* MM slash DD slash YYYY CAPTCHAΔ Have any questions? Contact us to arrange a call by filling in this form
