Health Monitoring Questionnaire

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– Step 1 of 3

Employee Name *

First

Last

Date of Birth *

Gender *

Weight *

Height *

Phone *

Email *

Site Suburb Name *

Mandatory tests included:
Audiometry + Spirometry

Optional Services

Healthy Heart Check (recommended)
Skin Cancer Check (recommended)

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General Health Questionnaire

If you answer ‘yes’ to any of the questions, please provide more details.

Did you suffer any incapacity lasting two weeks or longer in the last two years? *

Comments – Did you suffer any incapacity lasting two weeks or longer in the last two years? *

Have you ever had any operations or accidents or been hospitalised for any reason? *

Comments – Have you ever had any operations or accidents or been hospitalised for any reason? *

Are you currently being treated by a doctor or other health professional for any illness or injury? *

Comments – Are you currently being treated by a doctor or other health professional for any illness or injury? *

Are you currently receiving any medical treatment or taking any medications? Please detail. *

Comments – Are you currently receiving any medical treatment or taking any medications Please detail. *

Do you currently smoke? *

Do you practice personal hygiene at work, for example, frequent hand washing, eating or smoking, clean shaven, shower and change into clean clothes at end of shift? *

Specific Health Questions

If you answer ‘yes’ to any of the questions, please provide more details.

Do you have or have you ever had:

Shortness of breath on exertion *

Comments – Shortness of breath on exertion *

Wheezing, bronchitis or asthma now or in the past *

Comments – Wheezing, bronchitis or asthma now or in the past *

Any other lung or respiratory conditions (emphysema, pneumonia or sinusitis) *

Comments – Any other lung or respiratory conditions (emphysema, pneumonia or sinusitis) *

Allergies, hay fever, or allergic bronchitis *

Comments – Allergies, hay fever, or allergic bronchitis *

Does anyone in your immediate family (blood relatives only) have asthma, hay fever or eczema *

Comments – Does anyone in your immediate family (blood relatives only) have asthma, hay fever or eczema *

Significant weight loss *

Comments – Significant weight loss *

Any form of cancer *

Comments – Any form of cancer *

Any other significant health conditions *

Comments – Any other significant health conditions *

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Respiratory questionnaire

If you answer ‘yes’ to any of the questions, please provide more details.

Cough and Phlegm

1. Do you usually cough first thing in the morning? *

Yes 1 Do you usually cough first thing in the morning *

2. Do you usually cough during the day or at night? *

Yes 2 Do you usually cough during the day or at night? *

3. Do you cough like this on most days for as much as three months of the year? *

Yes 3 Do you cough like this on most days for as much as three months of the year *

4. Do you usually bring up phlegm from your chest first thing in the morning? *

Yes 4 Do you usually bring up phlegm from your chest first thing in the morning *

5. Do you usually bring up phlegm from your chest at any other rime of the day or night? *

Yes 5 Do you usually bring up phlegm from your chest at any other rime of the day or night *

6. Do you bring up phlegm like this on most days for as much as three months each year? *

Yes 6 Do you bring up phlegm like this on most days for as much as three months each year *

7. In the past three years have you had a period of increased cough and phlegm lasting for three weeks or more? *

Yes 7 In the past three years have you had a period of increased cough and phlegm lasting for three weeks or more *

8. If Yes, have you had more than one such period? *

Yes 8 If Yes, have you had more than one such period *

Breathlessness

9. Do you get short of breath when hurrying on level ground or walking up a slight hill? *

Yes 9 Do you get short of breath when hurrying on level ground or walking up a slight hill *

10. Do you get short of breath walking with other people of your own age on level ground? *

Yes 10 Do you get short of breath walking with other people of your own age on level ground *

11. Do you have to stop for breath when walking at your own pace on level ground? *

Yes 11 Do you have to stop for breath when walking at your own pace on level ground *

12. Have you at any time in the last 12 months been woken at night by an attack of shortness of breath? *

Yes 12 Have you at any time in the last 12 months been woken at night by an attack of shortness of breath *

Wheezing and chest tightness

13. Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months? *

Yes 13 Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months *

14. Have you ever had attacks of shortness of breath with wheezing? *

Yes 14 Have you ever had attacks of shortness of breath with wheezing *

15. If Yes, was your breathing absolutely normal between attacks? *

Yes 15 If Yes, was your breathing absolutely normal between attacks *

Smoking

16. Do you or did you smoke more than one cigarette/day; a cigar/week; two oz. pipe tobacco/month)? *

Yes 16 Do you or did you smoke more than one cigarette/day; a cigar/week; two oz. pipe tobacco/month) *

17. Do (did) you inhale smoke? *

If yes, indicate:

Slightly
Moderately
Deeply

18. How old were you when you started smoking regularly? *

19. Do (did) you smoke manufactured cigarettes? *

20. How many cigarettes do (did) you smoke per day on weekdays? *

21. How many per day on weekends? *

22. Do (did) you smoke plain or filtered cigarettes? *

23. What brands do (did) you usually smoke? *

24. Do (did) you smoke hand rolled cigarettes? *

25. How much tobacco do (did) you usually smoke per week in this way? *

26. Do (did) you put filters in these cigarettes? *

27. Do (did) you smoke a pipe? *

28. How much tobacco do (did) you usually smoke per week in this way? *

29. Do (did) you smoke cigars? *

30. How many of these do (did) you usually smoke per week in this way? *

31. If you are a present smoker have you been cutting down in the past year? *

32. If you are a past smoker when did you give up smoking altogether? *

Healthy Heart Check Questionnaire

SECTION 1 – Work Information

Work schedule

SECTION 2 – Cardiovascular Risk Assessment

(Aligned with Australian Cardiovascular Risk Guidelines)

Have you ever been diagnosed with:

High blood pressure
High cholesterol
Heart disease
Heart attack
Stroke
Peripheral vascular disease

Family History

Heart disease before age 55 (father/brother)
Heart disease before age 65 (mother/sister)

Alcohol intake per week

None
1–5 drinks
6–10 drinks
11+

How many days per week do you exercise?

None
1–2 days
3–4 days
5+

Do you experience:

Chest pain during exercise
Shortness of breath
Palpitations
Dizziness

SECTION 3 – Diabetes Risk Assessment

(Based on Australian Diabetes Risk Screening)

Have you ever been diagnosed with:

Prediabetes
Type 1 diabetes
Type 2 diabetes
Gestational diabetes

Family history of diabetes?

Parent
Sibling
Grandparent

How often do you consume: Sugary drinks

Never
1–3/week
Daily

How often do you consume: Processed foods

Rarely
Sometimes
Often

How often do you consume: Fruit and vegetables

Less than 2 servings/day
2–4 servings/day
5+ servings/day

Do you have:

Frequent thirst
Frequent urination
Unexplained fatigue
Weight gain around abdomen

SECTION 4 – Psychological Wellbeing Assessment

Workplace stress level (Scale 1-10)

Sources of stress

Workload
Shift work
Sleep disruption
Financial stress
Family responsibilities

Do you experience:

Anxiety
Low mood
Burnout
Difficulty concentrating
Poor motivation

Sleep quality

Excellent
Moderate
Poor

Average sleep hours

SECTION 5 – Nutrition & Dietary Behaviour

Typical breakfast

Typical lunch

Typical dinner

Snacking habits

Rare
Moderate
Frequent

How often do you eat: Fast food

Never
Weekly
Several times/week

How often do you eat: Vegetables

Daily
Occasionally
Rarely

Water intake

< 1 L/day
1–2 L/day
2 L/day

Do you follow a diet plan?

None
Low carb
Mediterranean
Weight loss diet

SECTION 6 – Physical Activity & Fitness

Weekly exercise minutes

0
<60 minutes
60–150 minutes
150 minutes

Types of activity

Walking
Gym training
Strength training
Cycling
Sport

Barriers to exercise

Time
Fatigue
Injury
Lack of motivation

SECTION 7 – Musculoskeletal Health

Do you experience pain in:

Neck
Lower back
Shoulders
Knees

Does your work involve:

Heavy lifting
Repetitive tasks
Prolonged sitting
Driving

Skin Cancer Screening History Form for Outdoor Workers

1. Current Occupation *

3. Previous Outdoor Occupations

Job Title and Duration

4. Average Daily Sun Exposure *

(years)

5. Use of Sun Protection (Check all that apply):

Sunscreen
Protective Clothing
Hats
Sunglasses
Shade Structures
None

Sunscreen SPF Level *

1. Personal History of Skin Cancer *

If yes, please provide Type, Date of Diagnosis and Treatment *

2. Family History of Skin Cancer *

If yes, please provide Relationship and Type *

3. History of Sunburns *

Frequency: *

(e.g., rarely, occasionally, frequently)

Severity *

(e.g., mild, blistering)

4. History of Tanning Bed Use *

Frequency: *

(e.g., never, occasionally, regularly)

Family Doctor

Suburb

1. Previous Skin Examinations by a Healthcare Professional

Date of Last Exam *

Findings *

2. Self-Examinations

Frequency: *

(e.g., monthly, yearly, never)

Findings: *

(e.g., new moles, changes in existing moles)

1. Recent Changes in Skin (within the last year):

New Moles or Spots

if yes New Moles or Spots *

Please provide details

Changes in Existing Moles or Spots (size, color, shape)

if yes Changes in Existing Moles or Spots (size, color, shape) *

Please provide details

Persistent Itching or Bleeding

if yes Persistent Itching or Bleeding *

Please provide details

2. Current Skin Concerns

Area of Concern *

Please provide details

Description of Concern *

Please provide details

2. Alcohol Consumption *

Frequency *

(e.g., never, occasionally, regularly)

3. Current Medications *

if yes 3. Current Medications *

Please provide details

4. Any Other Relevant Health Issues or Concerns *

Declaration *

I have read and understood the above, and I provide my consent.

Privacy and confidentiality
Employees Health collects your information to deliver the CPP Workplace Health Program. Your information is handled confidentially and stored securely.

Mandatory health monitoring (spirometry and audiometry)
I understand spirometry and audiometry are part of workplace health monitoring for CPP.
I consent to Employees Health providing CPP with a named health monitoring report for WHS purposes.
I understand CPP will use this information for workplace health monitoring and WHS management.

Voluntary wellbeing checks (healthy heart check and skin check)
I understand the healthy heart check and skin check are voluntary.
I understand the results of these voluntary checks are confidential to me and will not be shared with CPP.
Consent to contact
I consent to Employees Health contacting me to schedule and deliver the services I have selected and to provide my results.
Declaration
I declare that the information I have provided is true and correct to the best of my knowledge.

Did you receive any assistance by another person to complete this form? *

If Yes: provide details *

Signed *

Clear Signature

Date *

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EMPLOYEES HEALTH

Health Monitoring Questionnaire

General Health Questionnaire

Specific Health Questions

Respiratory questionnaire

Healthy Heart Check Questionnaire

SECTION 1 – Work Information

SECTION 2 – Cardiovascular Risk Assessment

SECTION 3 – Diabetes Risk Assessment

SECTION 4 – Psychological Wellbeing Assessment

SECTION 5 – Nutrition & Dietary Behaviour

SECTION 6 – Physical Activity & Fitness

SECTION 7 – Musculoskeletal Health

Skin Cancer Screening History Form for Outdoor Workers

EMPLOYEES HEALTH

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