"*" indicates required fields Step 1 of 5 20% This questionnaire will be CONFIDENTIAL to the Health Assured Occupational Health Team. The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. You may be contacted by the Health Assured team and may need to be seen by an Occupational Health Nurse or Doctor. We are an Equal Opportunities employer and applicants with disabilities are encouraged to apply for jobs. Candidate code cannot be confirmed or has expired or been cancelled- Please contact the person who issued the code to you.Employee DetailsName * REQUIRED First Last Any Previous or Alternative Name Date of Birth * REQUIRED DD slash MM slash YYYY Job Title * REQUIRED TitleMrMrsMsMxDrDaytime Tel: * REQUIREDEvening Tel:HiddenEmail * REQUIRED Home Address * REQUIRED Street Address Address Line 2 City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country General Practitioner DetailsGeneral Practitioner Name * REQUIRED General Practioner Address * REQUIRED Street Address Address Line 2 City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HiddenPost & School/Academy DetailsHiddenPost Applied For * REQUIRED HiddenName of School/Academy * REQUIRED HiddenAge range to be taught * REQUIRED HiddenDepartment * REQUIRED HiddenStart Date DD slash MM slash YYYY Past Employment with AuthorityHave you ever worked for the Authority before? * REQUIRED Yes No Hidden(If under a different name at the time please give previous name) Date(s) Employed HiddenName of Last Teaching Post (or initial teacher training college if newly qualified) HiddenAddress of Last Teaching Post Street Address Address Line 2 City County Postcode Please tick the appropriate box below and provide detailsHave you ever had any illness, medical problem or disability that may currently affect your ability to work safely as a teacher? * REQUIRED Yes No Comments * REQUIREDHave you ever been treated in hospital? * REQUIRED Yes No Please give reason(s) and dates * REQUIREDHave you seen a doctor in the last year for any kind of health problem? * REQUIRED Yes No Please give reason(s) * REQUIREDAre you having any treatment or investigations of any kind at the moment? * REQUIRED Yes No Comments * REQUIREDAre you waiting for any treatment, operation or investigation? * REQUIRED Yes No Comments * REQUIREDHave you ever had any illness or health related problem that may have been caused or made worse by your work? * REQUIRED Yes No Comments * REQUIRED Have you ever been medically retired from any job, or left any job because of ill health? * REQUIRED Yes No Comments * REQUIREDHave you had any days off sick in the last 2 years? * REQUIRED Yes No Please give number of days and reasons to the best of your recollection. * REQUIREDDo you have any eyesight problems not corrected with glasses? * REQUIRED Yes No Comments * REQUIREDDo you have any hearing problems? * REQUIRED Yes No Comments * REQUIREDDo you have any difficulties standing, bending or with any other movements? * REQUIRED Yes No Comments * REQUIREDDo you have any difficulties lifting? * REQUIRED Yes No Comments * REQUIREDHave you ever had any back problem? * REQUIRED Yes No Comments * REQUIREDHave you ever had any problem with your joints including pain, swelling or stiffness? * REQUIRED Yes No Comments * REQUIREDHave you ever suffered from any mental illness, psychological or psychiatric problem, including depression, anxiety, nervous debility, nervous breakdown, schizophrenia or eating disorder? * REQUIRED Yes No Comments * REQUIREDHave you ever had a drug or alcohol problem? * REQUIRED Yes No Comments * REQUIREDHave you ever had fits, blackouts or epilepsy? * REQUIRED Yes No Comments * REQUIREDHave you ever had any skin problems? * REQUIRED Yes No Comments * REQUIREDHave you ever had any heart or blood pressure problems? * REQUIRED Yes No Comments * REQUIRED Have you ever suffered from asthma, bronchitis or chest problems? * REQUIRED Yes No Comments * REQUIREDIn the last 12 months, have you had a cough for more than 3 weeks, coughed up blood or had any unexplained weight loss or fever? * REQUIRED Yes No Comments * REQUIREDHave you ever had hepatitis or jaundice? * REQUIRED Yes No Comments * REQUIREDDo you have any other medical conditions? * REQUIRED Yes No Comments * REQUIREDAre you on any medication at present? * REQUIRED Yes No Comments * REQUIREDDo you feel well at present? * REQUIRED Yes No Comments * REQUIREDAre you allergic to anything? * REQUIRED Yes No What? * REQUIRED DeclarationI declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I understand that if any recommendations to my employer are necessary as a result of this Work Health Assessment, Health Assured will discuss the recommendations with me before making them available to my employer. I agree to my information being stored and processed by Health Assured Occupational Health staff in a confidential manner according to the Data Protection Act. If you wish to access your records please request a Data Subject Access Request by contacting us. There may be a small administration charge for this.Please enter name as a signature * REQUIRED Date * REQUIRED DD slash MM slash YYYY
