Bakkafrost Initial Operator Health Assessment Questionnaire
SSC Initial Health Assessment Form V2.1
Bakkafrost Scotland Confidential Health Declaration
First Name
*
Second Name
*
Previous Name if applicable
Date of Birth
*
Address - First Line
*
Address - Town
*
Address - County:
*
Address - Post Code:
*
Physical gender at birth
*
Male
Female
Phone
*
Bakkafrost Scotland Location/Site
*
Job Title/Position:
*
Work Pattern
*
Do you have any disability, chronic health condition or are Neurodivergent?
*
Yes
No
Any health problems that may have been caused or made worse by work?
*
Yes
No
Do you need any special aids /adaptations to assist you at work, whether or not you have a disability
*
Yes
No
General Practitioner Information
General Practitioner Address:
*
Phone
General Health
Do you have any disability or chronic health condition?
*
Yes
No
If yes, please provide details
*
Any health problems that may have been caused or made worse by work?
*
Yes
No
If yes, please provide details
*
Do you need any special aids/adaptations to assist you at work, whether or not you have a disability?
*
Yes
No
If yes, please provide details
*
Food Safe
Have you or any of your close family suffered from any of the following?
Dysentery?
*
Yes
No
If yes, please provide details (including date)
*
Typhoid or Paratyphoid?
*
Yes
No
If yes, please provide details
*
Tuberculosis?
*
Yes
No
If yes, please provide details
*
Parasitic Infection?
*
Yes
No
If yes, please provide details
*
Hepatitis or jaundice?
*
Yes
No
If yes, please provide details
*
Skin disease / disorder?
*
Yes
No
If yes, please provide details
*
Have you suffered from any of the following in the last two (2) years?
Re-occurring skin rash?
*
Yes
No
If yes, please provide details (including date)
*
Re-occurring boils?
*
Yes
No
If yes, please provide details
*
Re-occurring discharge from ears, eyes or nose?
*
Yes
No
If yes, please provide details
*
Food poisoning or frequent gastric upset?
*
Yes
No
If yes, please provide details
*
If any YES answers recorded in the above refer to GP and designate as non- food handler until medical report received.
General Health
Asthma, bronchitis, other chest disease?
*
Yes
No
If yes, please provide details (including date)
*
Fainting attacks, giddiness, blackouts or epilepsy?
*
Yes
No
If yes, please provide details
*
Heart trouble?
*
Yes
No
If yes, please provide details
*
High blood pressure or stroke?
*
Yes
No
If yes, please provide details
*
Bowel disorder?
*
Yes
No
If yes, please provide details
*
Kidney or bladder condition?
*
Yes
No
If yes, please provide details
*
Arthritis or rheumatism?
*
Yes
No
If yes, please provide details
*
Diabetes?
*
Yes
No
If yes, please provide details
*
Thyroid or any glandular disorder?
*
Yes
No
If yes, please provide details
*
Skin disease?
*
Yes
No
If yes, please provide details
*
Eye disease or poor vision?
*
Yes
No
If yes, please provide details
*
Ear disease or deafness?
*
Yes
No
If yes, please provide details
*
Migraine or frequent headaches?
*
Yes
No
If yes, please provide details
*
Hepatitis or jaundice?
*
Yes
No
If yes, please provide details
*
Allergies or hay fever?
*
Yes
No
If yes, please provide details
*
Vibration white finger or disorders of hands or wrists?
*
Yes
No
If yes, please provide details
*
Disorders of arms or shoulder, neck or back?
*
Yes
No
If yes, please provide details
*
Respiratory
Cough
Do you usually cough during the day or at night in the winter? Do you cough like this in most days for as much as three months of each year?
*
Yes
No
If yes, please provide details (including date)
*
Do you usually bring up any phlegm from your chest?
*
Yes
No
If yes, please provide details
*
In the past three years have you had a period of (increased) cough and phlegm lasting for three weeks or more?
*
Yes
No
If yes, please provide details
*
Breathlessness
Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill or when walking with other people of your own age on level ground?
*
Yes
No
If yes, please provide details (including date)
*
Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months?
*
Yes
No
If yes, please provide details
*
Have you ever had attacks of shortness of breath with wheezing?
*
Yes
No
If yes, please provide details
*
During the past three years have you had any chest illness which has kept you from your usual activities for as much as a week?
*
Yes
No
If yes, please provide details
*
Have you ever had more than one illness like this in the past 3 years?
*
Yes
No
If yes, please provide details
*
Do you smoke or use an electronic cigarette/vape?
*
Yes
No
How many/much per day?
*
How long have you smoked?
*
Do you take regular exercise?
*
Yes
No
Type?
*
Amount per week?
*
Have your hobbies, secondary jobs or military reserve training ever involved any of the following? Please select your answers.
Orchestral or band playing
Power boating / skiing
Motor racing / Motor cycling
Attending loud music / clubbing
Diving
Work with Power Tools / Engines
Personal stereo /ear buds
Flying
Shooting
Have you ever used firearms?
*
Yes
No
What type of firearm?
*
How many rounds have you fired?
*
10
100
1000+
Were you ever exposed to other noise or explosions in military service?
*
Yes
No
If yes, please provide details
*
Do any members of your family have ear disease?
*
Yes
No
Which member?
*
Is any member of your family deaf?
*
Yes
No
Which member?
*
Have you noticed any whistling, ringing or other sounds in your ear?
*
Yes
No
If yes, please provide details
*
Have you ever had Earache, Discharge, Perforation?
*
Yes
No
If yes, please provide details
*
Do you have difficulty hearing in a crowded room?
*
Yes
No
If yes, please provide details
*
DECLARATION
I certify that the answers to the above questions are correct to the best of my knowledge. I understand that no medical details will be divulged without my permission to any person outside the Occupational Health Service, but an opinion about my fitness to work will be given to Management.
Enter your full name to confirm the above information
*
Submit
