The Keogh Practice - Occupational Health Unit

Pre-employment Questionarie
Private & Confidential

Sex M/F

Health Screening Questionnaire

1. General Medical History

  • 1. Hospital admission:

  • 2. Any other serious illness:

  • 3. Surgical operation:

  • 4. Family history of illness:

  • 5. Any recent medication:

  • 6. Any known allergies:

  • 2. Family History

  • 1. Diabetes:

  • 2. Blood pressure:

  • 3. TB:

  • 4. Epilepsy:

  • 5. Eczema:

  • 6. Mental Illness:

  • 7. Asthma:

  • 8. Cancer:

  • 9. Heart disease:

  • 3. Habits

  • 1. Do you smoke?:

  • 2. Did you ever smoke?:

  • 3. No. cigs. per day:

  • 4. Do you drink alcohol?:

  • 5. No. units per week:

  • 6. Do you exercise?:

  • 7. Alcoholism:

  • 8. Drug addiction:

  • 9. Illegal drug use:

  • 4. Eye, Ear, Nose & Throat

  • 1. Vision Defect:

  • 2. Hay Fever:

  • 3. Hearing Loss:

  • 4. Colourblindness:

  • 5. Sinusitis:

  • 6. Buzzing/ringing in ears:

  • 7. Other eye problems:

  • 8. Tonsillitis:

  • 9. Ear infections:

  • 5. Respiratory System

  • 1. Asthma:

  • 2. Wheeze:

  • 3. Pneumothorax:

  • 4. Bronchitis:

  • 5. Shortness of breath:

  • 6. Tuberculosis:

  • 7. Pneumonia:

  • 8. Coughing blood:

  • 9. Other lung disease:

  • 6. Glandular System

  • 1. Diabetes:

  • 2. Thyroid disease:

  • 3. Other glandular disease:

  • 7. Cardiovascular System

  • 1. High blood pressure:

  • 2. Palpitations:

  • 3. Rheumatic fever:

  • 4. Chest pain:

  • 5. Anaemia:

  • 6. Other heart disease:

  • 8. Musculoskeletal System

  • 1. Back pain or injury:

  • 2. Neck pain or injury:

  • 3. Upper limb pain or injury:

  • 4. Lower limb pain or injury:

  • 5. Hernia:

  • 6. Other musculoskeletal problem:

  • 9. Skin

  • 1. Dermatitis:

  • 2. Eczema:

  • 3. Skin allergy:

  • 4. Psoriasis:

  • 5. Dry skin:

  • 6. Acne:

  • 7. Other skin Problems:

  • 10. Digestive System

  • 1. Weight loss:

  • 2. Stomach/duodenal ulcers:

  • 3. Heartburn:

  • 4. Bloated abdomen:

  • 5. Passing blood:

  • 6. Passing mucus:

  • 7. Jaundice:

  • 8. Hepatitis:

  • 9. Recurring constipation:

  • 10. Recurring diarrhoea:

  • 11. Special diet:

  • 12. Other digestive disease:

  • 11. Genito-Urinary Systems

  • 1. Kidney disease:

  • 2. Urinary tract infections :

  • 11. 3. Females

  • i. Normal smear test?:

  • ii. Breast self-examination?:

  • iii. Menstrual problems:

  • 11. 4. Males

  • i. Testicular self-examination:

  • 12. Neurological System

  • 1. Blackouts:

  • 2. Recurring headaches:

  • 3. Anxiety:

  • 4. Fainting attacks:

  • 5. Recurring headaches:

  • 6. Migraine:

  • 7. Epilepsy:

  • 8. Mental health disorder:

  • 13. Occupational History

  • 1. Workplace injury:

  • 2. Manual handling accident:

  • 3. Off work more than 7 days in last 3 years:

  • 4. Workplace illness:

  • 5. Chemical accident:

  • 6. Failure to pass a previous medical examination:

  • 7. Any sleep problems:

  • 8. Use of respirator:

  • 9. Previous or ongoing compensation claim:

  • 10. Previous shiftwork or nightwork:

  • 11. Problems on shiftwork or nightwork:

  • 14. Audiogram History

    11. Do you wear ear protection?: