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Care At Home
Live-in Care, Home Care and Complex Care services in the comfort your own home, we are experts in ensuring you find the right help
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Occupational Health Questionnaire
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All the information on the form will be treated in strict confidence and will not be divulged to any third party without written consent.
Personal Details
Name
*
First
Last
Date
*
Branch
*
Bedford
Bedford
Brighton
Colchester
London
Live in
Norwich
Peterborough
Department
*
Staffing
Care at Home
Complex Care
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of Birth (DD/MM/YYYY)
*
Mobile
*
Email
*
Section A - Medical History
Please answer all of the following questions. If you answer Yes please give details.Have you ever had or do you have now, any of the following?
Impairment which may affect your ability to work safely?
*
Yes
No
Don't know
Details
Eyesight problems not corrected with glasses/contact lenses?
*
Yes
No
Don't know
Details
Hearing problems not corrected with a hearing aid?
*
Yes
No
Don't know
Details
Difficulty in standing, bending, lifting or other movements?
*
Yes
No
Don't know
Details
Any kind of back problem?
*
Yes
No
Don't know
Details
Have you ever suffered discomfort when using a computer keyboard?
*
Yes
No
Don't know
Details
Any mental illness or psychological problems e.g. depression nervouse breakdowns, eating disorder, substance misuse or other?
*
Yes
No
Don't know
Details
A drug or alcohol problem?
*
Yes
No
Don't know
Details
Fits, blackouts or epilepsy?
*
Yes
No
Don't know
Details
Any allergies?
*
Yes
No
Don't know
Details
Asthma, bronchitis or chest problems?
*
Yes
No
Don't know
Details
Treatment for TB?
*
Yes
No
Don't know
Details
In the last 12 months have you had a cough for more than 3 weeks, ever coughed up blood or had any unexplained loss of weight or fever?
*
Yes
No
Don't know
Details
Diabetes, thyroid or gland problems?
*
Yes
No
Don't know
Details
Any illness which may have caused or been made worse by your work?
*
Yes
No
Don't know
Details
Episodes of chest pain or breathlessness?
*
Yes
No
Don't know
Details
Suffer from heart disease or high blood pressure?
*
Yes
No
Don't know
Details
Are you at present taking or receiving any form of medication?
*
Yes
No
Don't know
Details
Any operations?
*
Yes
No
Don't know
Details
Been retired on the grounds of ill health?
*
Yes
No
Don't know
Details
Are you waiting for or receiving treatment for any medical or mental health
*
Yes
No
Don't know
Details
Have you ever suffered with stress associated with work?
*
Yes
No
Don't know
Details
Is there any additional relevant information regarding your health not covered in the above questions?
*
Yes
No
Don't know
Details
Section B - Food Handlers
You have a duty to report to your employer of any changes to your health.
Any skin conditions? (please specify)
*
Yes
No
Don't know
Details
Hepatitis or jaundice?
*
Yes
No
Don't know
Details
Dysentery, typhoid, paratyphoid, fever, food poisoning, salmonella, severe gastroenteritis or diarrhea?
*
Yes
No
Don't know
Details
Any discharge from ears or current/recurrent ear infections?
*
Yes
No
Don't know
Details
Section C - Sickness Absence
How many days have you lost from work or school during the past year?
*
What was this due to?
Section D - Immunisations / Blood Test Results
Certain jobs carry with them a risk of infection. In such cases we offer the facility of being immunised to prevent the risk of infection. Please provide details below of your immunisation history. When attending, please bring with you proof of identity e.g. passport or hospital identity badge.
Immunisations
HB test (Heaf, Tine, Mantoux)
Yes
No
Don't know
Date dd/mm/yy
Results
BCG [TB vaccinations]
Yes
No
Don't know
Date dd/mm/yy
Results
Tetanus
Yes
No
Don't know
Date dd/mm/yy
Results
Poliomyelitis
Yes
No
Don't know
Date dd/mm/yy
Results
Rubella [German Measles]
Yes
No
Don't know
Date dd/mm/yy
Results
Hepatitis A
Yes
No
Don't know
Date dd/mm/yy
Results
Hepatitis B (Date of last immunisation)
Yes
No
Don't know
Date dd/mm/yy
Results
Meningitis B
Yes
No
Don't know
Date dd/mm/yy
Results
Blood test results
Hepatitis B
Yes
No
Don't know
Date (DD/MM/YYYY)
Results
Rubella [German Measles]
Yes
No
Don't know
Date dd/mm/yy
Results
Varicella (Chicken pox)
Yes
No
Don't know
Date dd/mm/yy
Results
Chest X-ray [clear)?
Yes
No
Don't know
Date dd/mm/yy
Results
Others
Please state
Date dd/mm/yy
Results
Section E - HIV/AIDS
The company operates a policy of non-discrimination. In line with company policy, and National Guidelines, 'HSC 1998/226 - Guidelines on the Management of AIDS/HIV Infected Health Care Workers and Patient Notification' (updated August 1999), you must inform the Director of Training and Quality if you know or suspect you are HIV positive or have an AIDS defining illness. This information is necessary in order that a Risk Assessment may be undertaken to your safety and that of others.
If you know or suspect you are either HIV antibody positive or have AIDS, please tick the appropriate box. This information is absolutely confidential to the Director of Training and Quality.
Yes
No
Section G - Night Workers
The following section is to be completed only by those members of staff who regularly undertake night duty. Have you suffered from and been treated for any of the following. If Yes, please give details of the condition and whether they are ongoing at present.
Blackouts/Fainting fits/Epilepsy
Yes
No
Back or limb disorders
Yes
No
Diabetes
Yes
No
Heart or circulatory disorders
Yes
No
Stomach, bowel or intestinal disorders
Yes
No
Any conditions affecting sleep
Yes
No
Asthma/ bronchitis
Yes
No
Anxiety/depression
Yes
No
Nervous or mental disorders
Yes
No
Serious operations/accident/injuries
Yes
No
Do you have any other ongoing health problem?
Yes
No
Are you currently taking drugs or medicines prescribed by a doctor or purchased from a pharmacy?
Yes
No
Please give the name of the drug and dosage
Do you consider that you have any form of medical condition that may affect your ability to work at night?
Yes
No
Please explain
Have you ever felt that night work was harming your health?
Yes
No
Do you wish to discuss anything with a health advisor?
Yes
No
Section H - COVID-19 Vaccination Status
Please select from the options below your current vaccination status for COVID-19.
What is your current vaccination status?
*
First vaccination
Fully vaccinated
Not vaccinated
Section I - Declaration
I declare that the information on this form is true to the best of my knowledge. Further, I understand that if I should be found to knowingly make a false statement regarding my medical history either in answering the above questions or to the Company's Director of Quality and Training, or should I conceal any material fact, the Company can terminate my contract without notice.
Signature
Clear Signature
Phone
Submit
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