Initial / Pre Placement Operator Health Questionnaire

Health Declaration Operator Questionnaire V2.1

Please complete the following questions. The information will remain confidential to the Occupational Health service and will not be divulged to any other person without your consent.

 

Physical gender at birth

Please answer each question below and provide details if necessary

Do you have any disability, chronic health condition or are Neurodivergent?
Any health problems that may have been caused or made worse by work?
Do you need any special aids /adaptations to assist you at work, whether or not you have a disability?

Do you suffer from or have you ever suffered I experienced any of the following?

A Heart Attack?
Angina?
Swelling of a major artery(aneurysm) inside your chest or abdomen?
An operation on your heart/stent insertion?
Disease of the heart valves?
Asthma, bronchitis or any other chest disease?
High Blood pressure?
Diabetes? Type1/Type 2
A fit or Epileptic seizure?
Partial loss of consciousness, a blackout or faint?
Dizzy spells, Vertigo or a spinning feeling in the head?
An operation on your brain/brain tumour/bleed on the brain?
A stroke or Transient Ischaemic Attack (TIA)?
Do you have eye disease, double vision or wear glasses/lenses
Do you have any hearing issues/use hearing aids?
Have you ever had Cancer/Malignant Growth/ Tumour?
Joint problems/Pain/Swelling in joints/Mobility issues?
Do you have thyroid problems, over or underactive
Have you suffered with Stress/Anxiety of severe Depression that required prescription medication to treat?

Please complete box below if you have had previous noisy occupations?

Name of Employer

Occupation / Profession

Length of service

Ear protection worn

Hearing

Do you have to shout to make yourself heard at work?
If yes select frequency
Have you been exposed to noise in the last 12 hours
Is your hearing normal?
If not which ear?
Have you consulted your GP or specialist?
Have you had an injury/operation to your ears?
If yes, which ear?
Have you ever had a mastoid/surgery to your ears?
If yes, which ear?
Do you have difficulty hearing in a crowded room?
Have you noticed any whistling/ringing/other sounds in your ears?
Have you ever had infection/recurrent infections in your ears?
Have you ever had discharge from your ears?
Have you ever had a perforated ear drum?
Which ear?
Have you ever had an injury to the head which made you unconscious?
Do any family members have ear disease?
Are any family members deaf?
Have you ever had any of the following?
Do you suffer from Vertigo/Meniere’s/Labyrinthitis?
Have you been diagnosed with HAVS or white finger?
To your knowledge, have you ever had any drugs/injections for the following?
Have you ever used firearms?

How many rounds have you fired?
Did you wear hearing protection?
Have you ever served in the Armed Forces?
Were you exposed to explosions whilst serving?
Have your hobbies, secondary jobs or military reserve training ever involved any of the following? Please select your answers.

Respiratory

Cough

Do you usually cough during the day or at night in the winter?
Do you cough like this most days for as much as 3 months of the year?
Do you usually bring up phlegm from your chest?
In the past 3 years, have you had an increased period of cough and phlegm lasting more than 3 weeks or more?
Are troubled by shortness of breath when hurrying on level ground or walking up a slight hill?
Do you get short of breath walking with other people of your own age on level ground?
Have you had attacks of wheezing or whistling in your chest anytime in the last 12 months?
Have you ever had attacks of shortness of breath with wheezing?
During the last 3 years, have you had any chest illness which has kept you from usual activities for as much as a week?
Have you ever had more than one illness like this in the past 3 years?

Have you ever had or been told you have had any of the following?

An injury or operation affecting your chest?
Bronchitis/Pneumonia/Pleurisy?
Pulmonary Tuberculosis(TB)?
Asthma/Other chest Trouble?
Hay fever?
Do you have skin problems?

Smoking

Do you smoke?
Do you smoke hand rolled cigarettes?
Are you an ex-smoker?
Do you use an Electronic cigarette/Vape?
Do you smoke cigars or a pipe?

Vibrating Tools

Have any of your hobbies, secondary jobs or military reserve training ever involved any of the following?

Working near vibrating machines?
Working on buses, trucks or tractors?
Working with pneumatic drills, chainsaws, drills, etc?
Have you ever used hand held vibrating tools, machines or hand held processes in your job
Do you have any tingling of the fingers lasting more than 20 minutes after using vibrating equipment?
Do you have tingling of the fingers at any other time?
Do you wake at night with pain, tingling or numbness in your hand?
Do one or more of your fingers go numb more than 20 minutes after using vibrating equipment?
Have your fingers gone white on cold exposure?
If yes, do you have difficulty rewarming them when leaving the cold?
Do your fingers go white at any other time?
Are you experiencing any other problem with muscles or joints of the hands or arms?
Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars?
Have you ever had neck, arm or hand injury or operation?
Have you ever had any serious diseases of joints, skin, nerves, heart or blood vessels?
Are you on any long term medication?

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.