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1300 970 970
Refer Now
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Refer Now
Pre-Employment
Health Screen
Step
1
of
11
- Personal Details
9%
Information about this Questionnaire
This questionnaire is designed to assist Skilled Health in assessing your health status relevant to your employment. Information recorded on this form will be stored on a password protected electronic database and retained as part of your confidential file which is viewed only by the staff reviewing your workplace health requirements.
Please answer all sections, if you can provide us with this confidential information, your answers will assist us to perform an initial assessment and gather information.
Please ensure that answers are provided in all relevant fields. If you are uncertain about any of the following questions, please discuss them with the staff at the time of your health assessment.
Please answer truthfully and be sure not to provide false, misleading, or knowingly omit information which a reasonable person would expect to know about any physical or psychological injury or illness you may have which is relevant to the position you are applying for.
Personal Details
Full Name
*
Mobile Phone
*
Email Address
Date of birth
*
DD slash MM slash YYYY
Address
State
ACT
NSW
QLD
SA
TAS
VIC
WA
Postcode
Position applied for
Medical History
Do you have any physical or psychological disability or medical condition that would affect your ability to do job safely?
*
Yes
No
Details
Do you have any known allergies?
*
Yes
No
Details
Occupational Exposure History
Have you ever had problems working with the following: If yes, please give details in relevant section.
Dust/Fumes
*
Yes
No
Details
Chemicals/Soap/Latex
*
Yes
No
Details
Noise/Vibration
*
Yes
No
Details
Heat
*
Yes
No
Details
Radiation
*
Yes
No
Details
Occupational Exposure History
Have you suffered with, or do you suffer from any of the following conditions?
Epilepsy, fits, blackouts, fainting turns or dizzy spells
*
Yes
No
Migraines or frequent or severe headaches
*
Yes
No
Co-ordination abnormality, tremor or clumsiness
*
Yes
No
Hearing loss, tinnitus (ringing humming in ears) or deafness
*
Yes
No
Recurrent ear infections
*
Yes
No
Any heart condition including heart attack, heart murmurs or irregular heartbeat
*
Yes
No
Any lung conditions including asthma, pneumonia, chronic or recurrent bronchitis, wheezing, breathlessness or persistent cough
*
Yes
No
Hay fever
*
Yes
No
Any skin condition including eczema, psoriasis or dermatitis
*
Yes
No
Reaction to wearing protective gloves or problems wearing an other personal protective equipment (PPE)
*
Yes
No
Diabetes
*
Yes
No
Mental illness or nervous condition including anxiety, depression, phobia, psychosis or nervous breakdown
*
Yes
No
Any stress related illness
*
Yes
No
Occupational Exposure History
Have you suffered with, or do you suffer from any of the following conditions?
Neck injury, whiplash or other neck conditions
*
Yes
No
Back injury/condition including sciatica, disc lesion or disc prolapse
*
Yes
No
Any hand, arm or shoulder complaint/injury including rotator cuff injury, tenosynovitis, tendonitis, tennis elbow, carpal tunnel syndrome, nerve entrapments, RSI, overuse syndrome or other upper limb pain
*
Yes
No
Any foot or leg complaint/injury
*
Yes
No
Difficulty wearing safety shoes/boots
*
Yes
No
Arthritis or any joint condition
*
Yes
No
Do you have any problem(s) that may affect your safety or the safety of others? (e.g. daytime sleepiness, sleep apnoea)
*
Yes
No
Do you have any recurrent health problems that may interfere with your ability to attend work or perform your role? e.g. difficulties with shift work
*
Yes
No
Do you usually sleep well
*
Yes
No
Do you wake up during the night? Is this regular
*
Yes
No
Do you suffer a fear of heights, closed spaces or any other phobia
*
Yes
No
Note: If you have answered yes to any of the above questions, please provide details below.
Spirometry
What is Spirometry?
Spirometry is a clinical measurement that requires your active participation and cooperation in the procedure. Spirometry measures the maximal volume of air that you can exhale from your lungs as quickly as possible.
Our clinical staff will coach you how to do this test and you will be asked to repeat the exercise several times to obtain the best consistent results. Please ask the clinic staff if you have any questions.
You may feel some dizziness and/ or shortness of breath for a brief time after completing the test, please let our staff know if this happens or if you experience any other symptoms.
Spirometry is generally a safe test; we will check any potential risks or contraindications with you first.
Do you have Asthma/ bronchitis?
*
Yes
No
Do you have any dyspnoea (breathlessness)/cough/wheeze/cyanosis (blue tinge)
*
Yes
No
Do you use respiratory Medications/Bronchodilators (Puffers/Inhalers)?
*
Yes
No
Name of Inhaler
Dose
Do you have any history of any heart or lung conditions?
*
Yes
No
Heart/Lung conditions
Acute Myocardial Infarction (MI) (Heart attack)
Unstable heart issues (please discuss with clinic staff)
Angina
Arrhythmia
Severe hypertension (high BP)
Hypotension (low BP)
Heart failure
Pulmonary embolism
Pneumothorax
Have you had any surgical operations in the last three months?
*
Yes
No
Surgical operations
Eye (e.g., cataract)/ Middle ear/ Sinus/ ENT surgery/ Middle Ear Infection
Thoracic/ abdominal Surgery
Brain Surgery
Other
Details
Do you have any infections or active / transmissible respiratory disease?
*
Yes
No
Infection/Disease
Active or suspected transmissible respiratory disease or infection (including tuberculosis)
Conditions with potential infective risk
Haemoptysis (coughing up blood)
Increased secretions (nose/mouth/eye/ear)
Mouth lesions
Bleeding from mouth
Vomiting
Diarrhoea
Other
Are you currently pregnant?
*
Yes
No
Have you had any history of the below
*
History of syncope (fainting) related to cough or forced exhalation
Recent concussion with continued symptoms
Aneurysms
Late term pregnancy
None of the above
Lifestyle
Do you drink alcohol?
*
Yes
No
If you drink alcohol, on the average how often?
Please select
Less than once a week
On 1 or 2 days a week
On 3-4 days a week
On 5-6 days a week
Everyday
On the days that you do drink alcohol, on average how much do you drink?
Please select
1 or 2 standard drinks
3 or 4 standard drinks
5-8 standard drinks
9-12 standard drinks
13-20 standard drinks
More than 20 standard drinks
On the days that you do drink, what type of alcohol do you usually drink?
Please select
Beer full strength
Beer mid strength
Beer low strength
Wine
Spirits
Pre-mixed
Do you smoke?
*
Yes
No
How many per day?
How many years?
Have your ever smoked?
*
Yes
No
What year did you quit?
How many years?
Additional comments and information
Medical History
Do you have now, or have you ever had any of these conditions? If yes, please give a brief explanation.
Indigestion, heartburn or stomach ulcer
*
Yes
No
Details
Recurrent diarrhoea or constipation
*
Yes
No
Details
Vomiting of or passing blood
*
Yes
No
Details
Kidney, bladder or urinary problems
*
Yes
No
Details
Hernia or rupture
*
Yes
No
Details
Hepatitis or Liver problems
*
Yes
No
Details
Tumor, Cancer or Malignancy
*
Yes
No
Details
Any sinus, nose or throat problems
*
Yes
No
Details
Paralysis or weakness of any cause
*
Yes
No
Details
Injury or problem of any bones or joints (e.g. broken bones). Any other illness or injury, including surgical operations.
*
Yes
No
Details
Tuberculosis (TB)
*
Yes
No
Details
High blood pressure
*
Yes
No
Details
Have you taken any cold/flu medicines or tablets in the past month?
*
Yes
No
Details
Do you currently have a cold, the "flu" or any chest complaint?
*
Yes
No
Details
Medical History - Occupational
Do you have now, or have you ever had any of these conditions? If yes, please give a brief explanation.
Have you ever lived or worked outside Australia
*
Yes
No
Details
Have you suffered any illness or injury caused by your occupation
*
Yes
No
Details
Have you ever had difficulties wearing PPE
*
Yes
No
Details
Have your ever had a heat related illness or rash
*
Yes
No
Details
Have you ever worked with asbestos
*
Yes
No
Details
Have you ever worked with hazardous materials
*
Yes
No
Details
Have your ever been exposed to chemicals, dust or fume at work
*
Yes
No
Details
Have you ever been exposed to significant noise (occupational or other)
*
Yes
No
Details
Medications
Are you currently taking any of the following
Prescribed medication (a Doctor must give you a script for this in your own name)
*
Yes
No
Details
Over the counter medications (vitamins, pain killers, paracetamol, aspirin, anti-inflammatory, naturopathic remedies)
*
Yes
No
Details
Vaccination History
Have you ever been vaccinated against any of the following diseases. If yes, give approximate year you were vaccinated.
Vaccination
*
Influenza
Typhoid
Tetanus
Varicella (chickenpox)
TB - Tuberculosis
Polio
Hepatitis A
Hepatitis B
Meningococcal
Pneumonia
MMR - Measles, Mumps, Rubella
Q Fever
Whooping Cough
Diphtheria
Covid-19 First dose
Covid-19 Second dose
Covid-19 booster
Additional information
Application's Declaration and Authority
To be declared by the Applicant on 13/10/2024
Declaration
*
I have not knowingly withheld any information relevant to the pre-employment medical examination. I declare that the information provided in this Pre-Employment Health Screen form is true and correct.
Consent to Disclosure
I understand that the Company will require me to satisfactorily undergo a pre-employment Health Screen as a condition of appointment for the position to which I have applied. I authorise the examining staff member or the nominated medical practitioner to release any relevant information to the company designated manager/s that has scheduled my assessment.
I understand that information obtained in this Pre-Employment Health Assessment form and pre-employment Drug and Alcohol test will only be disclosed to the company designated manager/s. If persons other than the designated manager require access, this will only occur with my prior written consent, subject to the following exceptions:
1. Leaders in my direct line of management will be advised of my fitness to work, any work restrictions required, if there has been any excessive exposure to a hazardous agent at work or if a work-related injury or illness has occurred, that may affect my work with them in my role. However, any clinical medical details will only be disclosed with my prior written consent; and
2. Information will be disclosed in response to a court order, if required by legislation or in specific legal circumstances permitted under applicable Privacy Legislation.
Right of Access
I understand that I have the right to access, and where necessary correct, personal health information held about me by the Company. To obtain access I understand that I will need to contact the Company designated manager/s.
