Nightshift Workers Questionnaire
Nightshift Workers Questionnaire
Confidentiality
Full Name
*
Date of Birth
*
Company Name
*
Job Title/Position
*
Work Pattern
*
Phone
*
Consent & Declaration
I give my consent for Albacare Limited to carry out a health assessment for night time work. I understand that this is necessary for health and safety reasons and the results of this assessment, including recommendations (but not the detailed medical findings) will be given to my employer, to assist in maintaining a healthy and safe workplace. I declare that, to the best of my knowledge, the information given above and in the answers to the health questionnaire is true and complete. I understand that failure to disclose relevant information or providing false information may affect my employment.
I give my consent
Yes
No
Do you currently work permanent night shifts?
Yes
No
If yes, please provide details
*
Do you currently work a rotating shift system which includes nights?
Yes
No
If yes, please provide details
*
Do you have any concerns about your health at present?
Yes
No
If yes, please provide details
*
Have you ever had?
Epilepsy/fainting attacks/blackouts?
Yes
No
If yes, please provide details
*
Depression / anxiety mental illness/nervous debility?
Yes
No
If yes, please provide details
*
Migraine/frequent headaches?
Yes
No
If yes, please provide details
*
Kidney/bladder trouble?
Yes
No
If yes, please provide details
*
Arthritis/rheumatism/back trouble?
Yes
No
If yes, please provide details
*
Ear trouble?
Yes
No
If yes, please provide details
*
Eye trouble?
Yes
No
If yes, please provide details
*
Dysentery/hepatitis/typhoid/paratyphoid?
Yes
No
If yes, please provide details
*
Do you suffer from?
Diabetes – Type 1 or Type 2?
Yes
No
If yes, please provide details
*
Heart or circulatory problems?
Yes
No
If yes, please provide details
*
A medical condition where regular timing of meals important? *
Yes
No
If yes, please provide details
*
A chronic chest disorder?
Yes
No
If yes, please provide details
*
A sleeping disorder or medical condition affecting your sleep?
Yes
No
If yes, please provide details
*
Are you currently on prescribed medication?
Yes
No
If yes, please provide details
*
Are you aware of any other health matters that may affect your fitness to undertake night duties?
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
