Employee Fitness for Work Questionnaire "*" indicates required fields By completing this form I am acknowledging that I can understand and read everything that is required of me and that I am completing this form myself, truthfully.Employee (full name):*Date of Birth:* DD slash MM slash YYYY Position:*Signature*Date* DD slash MM slash YYYY Please complete the following questions by ticking either 'yes' or 'no'.Are you currently being treated by a doctor for any injury or illness?* Yes No If 'Yes', please describe below.*Are you currently taking any medication that has been prescribed by a doctor?* Yes No If 'Yes', please describe below.*Have you ever broken any bones or sustained a serious injury?* Yes No If 'Yes', please describe below.*Are you allergic to any material or medication?* Yes No If 'Yes', please describe below.*Do you, or have you had any condition which prevents you from wearing safety clothing or equipment?* Yes No If 'Yes', please describe below.*Have you ever been regularly exposed to:* Loud noise Chemicals Asbestos Other dusts Radiation Yes No If 'Yes', please describe below.*Do you have any phobias, for example, heights, confined spaces, flying?* Yes No If 'Yes', please describe below.*Do you have any problems sleeping, suffer from insomnia or nightmares?* Yes No If 'Yes', please describe below.*Have you ever suffered from, or do you suffer from any of the following?Chest pain, angina, heart disease or cardiac surgery?* Yes No If 'Yes', please describe below.*High or low blood pressure?* Yes No If 'Yes', please describe below.*Lung conditions such as asthma, bronchitis, tuberculosis?* Yes No If 'Yes', please describe below.*Shortness of breath or wheezing?* Yes No If 'Yes', please describe below.*Hearing loss, difficulty hearing or ringing in the ears?* Yes No If 'Yes', please describe below.*Blackouts, fits or epilepsy?* Yes No If 'Yes', please describe below.*Diabetes or sugar disease?* Yes No If 'Yes', please describe below.*Back or neck pain or injury, sciatica, whiplash or slipped disc?* Yes No If 'Yes', please describe below.*Skin conditions such as dermatitis or eczema?* Yes No If 'Yes', please describe below.*Head injury or concussion?* Yes No If 'Yes', please describe below.*Hernia – umbilical or inguinal?* Yes No If 'Yes', please describe below.*Arthritis, rheumatism or joint pain?* Yes No If 'Yes', please describe below.*Knee or ankle problems, joint injury such as cartilage or tendon injur* Yes No If 'Yes', please describe below.*Stomach pains or ulcers?* Yes No If 'Yes', please describe below.*Chronic ear infections?* Yes No If 'Yes', please describe below.*Diseases or disorders of the nervous system?* Yes No If 'Yes', please describe below.*Episodes of numbness or weakness?* Yes No If 'Yes', please describe below.*Repetitive strain injury, tenosynovitis, over-use syndrome or wrist strain?* Yes No If 'Yes', please describe below.*Are any of the following going to affect your ability to work?Dietary habits?* Yes No Please clarify*Exercise routines?* Yes No Please clarify*Stress levels?* Yes No Please clarify*Hot working conditions?* Yes No Please clarify*Fatigue?* Yes No Please clarify*Alcohol consumption?* Yes No Please clarify*Drugs or medications not prescribed by a doctor?* Yes No Please clarify*Are you aware of any reason that would prevent you from working in the following conditions?Shift work, including night shift?* Yes No Please clarify*Performing heavy manual handling?* Yes No Please clarify*In wet conditions?* Yes No Please clarify*In dusty conditions?* Yes No Please clarify*In hot and humid conditions?* Yes No Please clarify*At heights?* Yes No Please clarify*In confined spaces?* Yes No Please clarify*While wearing safety footwear or other personal protective equipment such as safety harness, ear plugs or respirator?* Yes No Please clarify*Medical certificateMax. file size: 20 MB. The questions asked on this form may be used to assist in the assessment of a person’s fitness to carry out the work for which they may be employed. Pre-existing medical conditions not disclosed on this questionnaire which render personnel unfit for work, may result in leaving the work site at the employee's expense.To be signed by employeeI hereby declare that I have answered the above questions to the best of my knowledge and understand that pre-existing medical conditions not disclosed now that arise on site and affect my work ability may result in me leaving the work site at my own expense. I will inform my supervisor immediately should my physical condition or capability change that will prevent me from carrying out the job.Name*Date* DD slash MM slash YYYY Signature*
