Annual Health Questionnaire

• Your Name

Select your name:

• Occupation/Role/Trade

• Date of Birth

• Current Age

• Completed on

  Date

• Any pre-existing medical conditions (Note: you only need to report problems that may affect your work)

  Yes

  No

• The purpose of this questionnaire is to ensure, so far as is possible, that you are fit to work, to protect your own and others' health and safety at work. This questionnaire is also designed to assess whether there are any existing health issues likely to affect your current job role and to find out if any changes need to be made to your current working arrangements to accommodate these issues.
  
  The information you provide in this questionnaire will be retained in your personal file throughout your employment. However, please be assured that all information supplied within this questionnaire will remain strictly confidential and can only be accessed by authorised personnel.
  
  You must be truthful and accurate with the answers you provide, although there is no need to report trivial problems. When you declare NO, you are accepting a degree of responsibility for your safety. If in doubt, you should seek medical advice and, where applicable, tell your employer.

Dust & Fumes

• Within the last 12 months have you had any of the following symptoms either at work or at home? (Do not include isolated colds, sore throats or flu.)

• Bouts of coughing?

  Yes

  No

• Chest tightness?

  Yes

  No

• Wheeze?

  Yes

  No

• Breathlessness?

  Yes

  No

• Have you consulted your doctor about any chest problems since the last questionnaire?

  Yes

  No

Hand Arm Vibration

• Within the last 12 months;

• Are you regularly required to operate vibrating tools for prolonged periods of time i.e. for more than two hours a day on a daily basis?

  Yes

  No

• Do you have any numbness or tingling of the fingers lasting more than 20 minutes after using vibrating equipment?

  Yes

  No

• Do you have numbness or tingling of the fingers at any other time?

  Yes

  No

• Do you wake at night with pain, tingling, or numbness in your hand or wrist?

  Yes

  No

• Have any of your fingers gone white on cold exposure?

  Yes

  No

• Have you noticed any change in your response to your tolerance of working outdoors in the cold?

  Yes

  No

• Are you experiencing any other problems in your hands or arms?

  Yes

  No

• Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars?

  Yes

  No

Noise

• Within the last 12 months;

• Are you regularly required to work in areas where you experience high levels of noise continuously for prolonged periods of time (i.e. for 2 or more hours a day)?

  Yes

  No

• Have you noticed deterioration in any aspect of your hearing?

  Yes

  No

• Do you have any difficulty hearing normal conversation?

  Yes

  No

• Do you have difficulty following a conversation when two are more people are speaking at the same time?

  Yes

  No

• Have you experienced any trouble hearing over the telephone?

  Yes

  No

• Do you often misunderstand things people say or do you feel people mumble or do not speak properly?

  Yes

  No

• Have any of your family or friends said that they think you may have hearing loss?

  Yes

  No

Skin Health

• Within the last 12 months;

• Have you experienced any dryness, redness or itching on your hands or arms?

  Yes

  No

• Have you developed any flaking or scaling skin on your hands or arms?

  Yes

  No

• Have you experienced any cracking, swelling or blistered skin on your hands or arms?

  Yes

  No

General Fitness

• Visual Acuity; Within the last 12 months;

• Do you have difficulty seeing (with glasses or contact lenses if needed) for all normal work purposes?

  Yes

  No

• Have you noticed deterioration in any aspect of your vision, including a difficulty differentiating between certain colours?

  Yes

  No

• Musculo-skeletal Problems; Within the last 12 months;

• Have you experienced any aches or pains particularly in the back, neck or shoulders?

  Yes

  No

• Have you experienced any recurrent aches or pains in one particular part of your body?

  Yes

  No

• General Health: Within the last 12 months;

• Have you suffered blackouts, recurrent dizziness, or any condition which may cause sudden collapse or incapacity?

  Yes

  No

• Do you have any problems affecting your ability to stand, lift/bend, use hands, walk/run, climb, work at heights or in confined spaces, or which may affect your work in anyway?

  Yes

  No

• Do you consider yourself to have any illness/impairment/ disability (physical or psychological), which may require an adjustment in terms of access or special equipment or any other change to your job?

  Yes

  No

• Have you been advised by your Doctor or other Health Professional to give up or change your job, or not to do any specific kind of work?

  Yes

  No

• Are you suffering from an illness or injury that may be made worse by work e.g. skin or chest problems such as dermatitis, psoriasis, bronchitis or asthma?

  Yes

  No

• Are you under the care of a doctor or receiving medical treatment or waiting treatment or a medical appointment?

  Yes

  No

• Has anything else changed about your health since the last questionnaire that hasn’t been covered above and may have a bearing on your health and/ or safety at work?

  Yes

  No

• If you answered yes to any of the questions above, please provide further details:

Declaration

• I declare that the information given is true to the best of my knowledge. I further declare that I have not omitted or falsified any facts or details that could affect my health. I am aware that I should notify AB Civils of any changes to my health that could be related to my work or that could potentially affect my ability to undertake safety-critical tasks.

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