ࡱ> Y  .bjbjWW ==]DBBBBVB&t^(0%%%%%%%$?'3)%"%B"0B"B"B"%BB%B"B"%R%4%*dP+BB 8%FRAME HOMES SW LTD PRACTICAL DEVELOPMENTS SW LTD PERRAN TRUSSES CONFIDENTIAL PRE-EMPLOYMENT HEALTH QUESTIONNAIRE Post applied for: FORMTEXT      Department: FORMTEXT      Surname: (Dr/Mr/Mrs/Miss/Ms) FORMTEXT      Forename(s): FORMTEXT      Date of birth:  FORMTEXT       (day)  FORMTEXT       (month)  FORMTEXT       (year)National Insurance No: FORMTEXT      Address: Telephone No: FORMTEXT        FORMTEXT      Present Post: FORMTEXT      How long post held: FORMTEXT      Name and address of General Practitioner:  FORMTEXT       Telephone No:  FORMTEXT      MEDICAL HISTORYHave you suffered from any of the following? Please tick as appropriate and provide details. If necessary, continue on a separate sheet.YESNODetails (including dates)Any skin disease(s) Discharge or infection of the ears or hearing defect Asthma or hayfever of sufficient severity to require time off work or school Any allergies (including sensitivity to antibiotics or other drugs) Psoriasis Recurrent sore throats or sinusitis Bronchitis or pneumonia Tuberculosis Lung disease Heart disease or high blood pressure  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       YESNODetails (including dates)11. Headache or migraine requiring time off work or school Fits, blackouts or epilepsy Depression, nervous breakdown or mental illness, psychiatric treatment, anorexia Eating Disorders Stomach Ulcer Abdominal complaint requiring time off work or school Diabetes Kidney or bladder infection Joint pain Eye disease, injury or significant defect of vision not corrected by spectacles Colour blindness Dyslexia Serious accident Jaundice Backache or sciatica requiring time off work or school Rupture, varicose veins or foot ailments Repetitive Strain Injury (RSI) Have you ever been admitted to hospital? If yes, give details Do you suffer from any defect or disability not included in the above? If yes, give details FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       OCCUPATIONAL HISTORY How many days have you had away from work or school for illness (including period problems) over the past three years?  FORMTEXT       days. Briefly state reason(s):  FORMTEXT      Are you regularly receiving injections, pills, tablets or medicines from a doctor (other than contraception)? If so, give details:  FORMTEXT       Have you been exposed to any of the following hazards?DustYes  FORMCHECKBOX  No  FORMCHECKBOX Mineral OilYes  FORMCHECKBOX  No  FORMCHECKBOX NoiseYes  FORMCHECKBOX  No  FORMCHECKBOX FumeYes  FORMCHECKBOX  No  FORMCHECKBOX VibrationYes  FORMCHECKBOX  No  FORMCHECKBOX TarYes  FORMCHECKBOX  No  FORMCHECKBOX VDUYes  FORMCHECKBOX  No  FORMCHECKBOX RadiationYes  FORMCHECKBOX  No  FORMCHECKBOX ChemicalsYes  FORMCHECKBOX  No  FORMCHECKBOX LeadYes  FORMCHECKBOX  No  FORMCHECKBOX AsbestosYes  FORMCHECKBOX  No  FORMCHECKBOX OtherYes  FORMCHECKBOX  No  FORMCHECKBOX Have you ever had to give up any previous job for medical reasons?Yes  FORMCHECKBOX  No  FORMCHECKBOX Have you in the past received compensation for any industrial injury or illness?Yes  FORMCHECKBOX  No  FORMCHECKBOX Have you ever had an illness that caused you to be absent from work for more than three months?Yes  FORMCHECKBOX  No  FORMCHECKBOX  FAMILY HISTORY Have you or your family (blood relatives only) suffered from heart disease, asthma or any hereditary diseases?Yes  FORMCHECKBOX  No  FORMCHECKBOX Does any of your close family have any chronic health problems?Yes  FORMCHECKBOX  No  FORMCHECKBOX If so, give details:  FORMTEXT       Do you wear spectacles?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you smoke now?Yes  FORMCHECKBOX  No  FORMCHECKBOX Quantity per day? FORMTEXT      Have you smoked in the past? Age Stopped Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT       Quantity per day?  FORMTEXT      What is your weekly alcohol consumption? FORMTEXT       UnitsHow tall are you? FORMTEXT       MetresWhat do you weigh? FORMTEXT       Kilos Please record the last date that you received immunisation for the following:DateDateTetanus FORMTEXT      Poliomyelitis FORMTEXT      Rubella (German Measles) FORMTEXT      Hepatitis A FORMTEXT      BCG (for Tuberculosis) FORMTEXT      Hepatitis B FORMTEXT      Date of last chest x-ray  FORMTEXT       I understand and acknowledge, that should I knowingly make a false statement regarding my medical history, either in answering the above questions or the questions of any medical examiner, or should I wilfully conceal any material fact, I will, if engaged, be liable to have my employment with the Company terminated and I understand I will have no rights of recourse. In the event of any health queries, I consent to my General Practitioner supplying relevant information to the Medical Examiner or a Director of Frame Homes SW Ltd, Practical Developments SW Ltd or Perran Trusses.Signed:Date: FORMTEXT        J P Services  DATE \@ "yyyy" \* MERGEFORMAT 2005  PAGE 4  TIME \@ "dd MMMM yyyy" 18 March 2005  CREATEDATE \@ "dd/MM/yy" \* MERGEFORMAT 27/10/03  FILENAME \p \* MERGEFORMAT D:\J P Services\F\Frame Homes (SW) Limited\Forms\Medical Questionnaire.dot    "$.04LNbdfprv  <>RTV`bdnprjDCJUjCJUj\Uj6UmHj6U6 j6U6CJjCJUmHjtCJU jCJU jUmHjU jUCJCJ8&b 24LtvȄLn$/$$lH0 '/$$lH0 '$&b 24Ltv: 46Hd"JL  ~ytpkfb      0  D  X  fg  {            $  34  H  U  i  }          $: 46Hd4RMJ$$<$$l4F9!'n$ 9r 5 n$ 9r >U5  n$ 9r E$$l\ '  "$&026dfz|~ "$8:<FHLjvCJUjUjUjU jUmHjU jUj,CJU6CJjCJUmHjCJUCJ jCJU  R  S  g  {                          '  9  K  ]  oBCDESTUWXfghijtu  &(*46:<PRT^`bdxz|j)Uj(Uj(Uj'Uj,'Uj&Uj@&U jUmHj%UjR%Uj$U jU@b,TV~Fnp $ & F,$$$ & F$(*,.BDFPRVXlnpz|~  468BDFH\^`jlprj*-Uj,Uj>,Uj+UjR+Uj*Ujf*Uj)Ujz)U jUmH jUCFnp&'(-Xdü~rnib[TM      J  O  PQ      &  '   6 7  K  L  `  t  u           "$&02xzFz%(-12@ABFGUӸৱj/U5jx/CJUjCJUmHj/CJU jCJUj>*CJUmHj.>*CJU>*CJj>*CJU6CJCJj.U jUmHj-U jU6lyj & F$ o e$  $$$l\' $  E$$lm2\}'&'(-Xdl$$$$$$$l\'$$$$l\'UVWXdhiwxy}~%&'(,01?@AEFTUVZj4Ujv4Uj4Uj3Uj3Uj2Uj22Uj1UjJ1Uj0U5 jUjb0U?(,WXYZ^&/Z`}ytmf_XQ    H  Q  |                        K  O  z              (,WX\$$$$s$$lJ4ִ\1/.-+* )&'`` XYZ^&/p`$$$$s$$lJ4ִ\1/.-+* )&' Z^bcqrswx#$%&/34BCDHIWXYZ`desjr9Uj8Uj8Uj8Uj7Uj.7Uj6UjF6Uj5Uj^5U jU5@/Z`s$$lJ4ִ\1/.-+* )&' $$$$ stuyzPTUcdeijxyz}~    !j=Uj=Uj=Uj<Uj*<Uj;UjB;Uj:UCJ5jZ:U jUj9U?`P{|}~   $!%!&!Ľ~ytpd_ZV     T  !U  V     klm  n          '  x  yz  {          P{|}~ f8G$$l4\\1* )&'$$$$G$$lq4\\1* )&'   $!%!s:$$lF\ "&'$$G$$l-4\\1* )&' ! !!!!!!"!#!&!;!#@#T#V#X#b#d######## $jBCJUjACJUj(ACJUj@CJUj@@CJUj?CJUjCJUmHjV?CJU jCJUCJj>U jUjn>U6%!&!""""D""""Ĭ|yyy$$1$$l40\"&' & F$  & F$ 0 :$$lF\ "&' &!""""D""""""#>#f#h###$:$<$>$b$d$$$$%%:%˿|wrnb]YM :  &;  U ~  %                   $  &  8  c u  #v  w  x     "     """#>#f#h###$:$kLb[[ & F$ & Fo$G$$l4\\f& '$$G$$l4\\f& ' $$$$$($*$,$6$8$d$f$z$|$~$$$$$$$$$$%%%8%:%<%P%R%T%^%`%b%p%r%%%%%%%%%%l&p&&&&&&&&&&&ɼjHECJUjDCJU jUmHj\DU jUmHjCCJUCJmHjpCCJUjCJUmHjBCJUCJ jCJUjBCJU::$<$>$b$d$$$$%%:%r%pxk $d$  ed$1$$l40\&'$G$$l4\\f& '$ :%r%%%%%%n&p&r&|&~&&&&&&&&&''':'T'^'b'z''''''''''(,(6(:(<(n((((((((++++++ ,,,,,,,,,, ,",$,,....       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