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Section 1:

Employee Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

Date of Birth *

Gender *

Weight *

Height *

Company Employed By *

Employment Start Date *

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Section 2:

Your health history – Since your last health assessment

Have you been / are you currently being treated for any medical condition?

Do you expect to consult a doctor or expect to receive any treatment in the near future?

Have you been admitted to hospital?

Have you ever been exposed to toxic substances or environmental hazards?

Have you had trouble wearing (PPE) personal protective equipment, safety equipment or breathing apparatus?

If you answered ‘Yes’ to any of the above please provide details: *

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Section 3:

Medical History – Are you or have you ever received treatment or medical advice for any of the following?

Neurological:

Irritability

Anxiety/Depression

Other mental health issues

Reduced memory or concentration

Persistent headaches / Migraines

Muscle weakness

Numbness in hands or feet

Sleep disorders / Excessive tiredness

Gastrointestinal:

Bowel Problems / Nausea / Diarrhoea

Loss of appetite

Stomach problems / Ulcers

Crohn's disease

Cardiovascular:

Blood pressure / Heart problems / Chest pain

Renal / Liver:

Liver problems / Hepatitis

Kidney / Bladder problems

Other Medical Conditions:

Eye troubles (other than glasses)

Bruising / Excessive bleeding

Recent weight loss or gain

Thyroid disease

Cancer / other tumour

If you answered ‘Yes’ to any of the above please provide details: *

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Section 4:

Smoking

Do you or did you smoke more than 1 cigarette/day; a cigar/week; 2oz pipe tobacco/month?)

Details *

Do (did) you inhale smoke?

If Yes *

slightly
moderately
deeply

How old were you when you started smoking regularly?

How much do (did) you smoke per day on day? (number of cigarettes)

If you are a past smoker when did you give up smoking altogether

Dr to provide comments for any ‘Yes’ responses: (reference Q No.)

Hazardous Substance Exposure

Please select all hazardous substances you are currently exposed to in your work: *

4,4'-Methylene bis (2-chloroaniline) (MOCA)
Acrylonitrile
Antimony
Arsenic
Asbestos
Benzene
Beryllium
Butanone (MEK)
Cadmium
Chromium
Carbon disulfide
Cobalt
Creosote
Crystalline silica
Cyclophosphamide
Dichloromethane
Ethylbenzene
Fluorides
Isocyanates
Lead (inorganic)
Mercury (inorganic)
Methyl isobutyl ketone (MIBK)
Nickel
Organophosphate pesticides
Pentachlorophenol
Polycyclic aromatic hydrocarbons (PAHs)
Styrene
Tetrachloroethylene
Thallium
Toluene
Trichloroethylene
Uranium
Vinyl chloride
Xylene
Other (please specify)

Please specify the hazardous substance(s)

Section 5:

Exposure History

How many years have you worked at your present work?

How often are you in contact with chemicals each day?

Occasionally (less than 15 min/day)
15 min - less than 1 hour
1 hour - 4 hours
4 hours or more/day

How many hours per day do you usually work?

Before this work were you employed in a job involving chemical/hazardous substance exposure? If so, please indicate how long you have worked with chemicals

When you are undertaking tasks with chemical exposure or potential exposure do you use personal protective equipment?

If yes please indicate the type of equipment used and how often

Hand

Never
Occasionally (<50%)
Sometimes (50-79%)
Usually (80 – 100%)

Body

Never
Occasionally (<50%)
Sometimes (50-79%)
Usually (80 – 100%)

Eyes

Never
Occasionally (<50%)
Sometimes (50-79%)
Usually (80 – 100%)

Respiratory

Never
Occasionally (<50%)
Sometimes (50-79%)
Usually (80 – 100%)

Do you wear disposable protective garments? If so, how are they disposed of?

Does your workplace use ventilation systems?

If yes please indicate type

Local exhaust systems (booths, elephant trunks, hoods)
Wall or rood mounted propeller fans
Natural ventilation

If you use respiratory protection, how many years have you used a “face” mask or respirator?

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Section 6:

Workplace Hygiene

Do you usually wash your hands before eating, drinking or smoking?

Do you change your clothes after work, before you go home?

Do you ever eat, drink or smoke on the job?

Do you shower before you go home?

Do you have an area to eat that is away from your work area?

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Section 7:

Declaration *

I declare that I have answered the above correctly and completely, to the best of my knowledge

Please read the following and sign where indicated

Statement authorisation - I give my consent for the results of my medical examination to be given to my employer. I understand that my employer is obliged to keep my results in a secure and confidential manner. I also give my consent for the release of information contained in the health surveillance assessment to my treating or family doctor.

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

If Yes: provide details *

Signed *

Clear Signature

Date *

EMPLOYEES HEALTH

Employee Questionnaire

Section 1:

Section 2:

Your health history – Since your last health assessment

Section 3:

Medical History – Are you or have you ever received treatment or medical advice for any of the following?

Neurological:

Gastrointestinal:

Cardiovascular:

Renal / Liver:

Other Medical Conditions:

Section 4:

Smoking

Hazardous Substance Exposure

Section 5:

Exposure History

Section 6:

Workplace Hygiene

Section 7:

EMPLOYEES HEALTH

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