Step 1 of 5 20% New Starter Medical Questionnaire To be completed by employee - PLEASE CLICK YES OR NO FOR EACH QUESTIONName* First Last Home address* Street Address Address Line 2 City Postcode Home telephone*Mobile phone*Date of birth* Job title / description*Please give your proposed job title and if possible a brief description of the work 1. Do you smoke?*YesNo2. Are you an ex-smoker?*YesNo3.Do you have difficulty with your eyesight when performing day-to-day activities, even with glasses/contact lenses?*YesNo4. Do you have difficulty with your hearing, including using a telephone, even with a hearing aid if one is usually used?*YesNo5. Have you ever had any operations or been admitted to hospital?*YesNo6. Are you currently attending any hospital, clinic or outpatient department?*YesNo7. Have you undergone surgery or been admitted to hospital in the last 2 years?*YesNo8. Have you ever left or been denied a job due to medical reasons?*YesNo9. Do you have any symptoms which prevent you from going to work?*YesNo10. Are you or have you ever been registered Disabled?*YesNo11. Have you ever suffered from any medical condition you consider to have been caused by work?*YesNo12. Do you have any medical condition or disability that you feel will affect your ability to carry out this role?*YesNo13. Have you ever been treated for alcohol or drug related problems or been advised to reduce your alcohol intake?*YesNo14. Do you need any special aids or adaptations to assist you at work, whether or not you have a disability?*YesNoYou have answered YES to one or more questions in the above section. Please give more details, including dates, time lost at work and any treatment provided / being provided.* Have you ever suffered from:15a. Fainting attacks & giddiness*YesNo15b. Sinusitis*YesNo15c. Recurring Headaches / Migraines*YesNo15d. Foot or Knee Trouble*YesNo15e. Kidney or Bladder Disease*YesNo15f. Blackouts, Epilepsy or Fits*YesNo15g. Raised Blood Pressure*YesNo15h. Asthma*YesNo15i. Latex Allergy Diagnosis*YesNo15j. Any Musculo-Skeletal disorder such as back, joints, bones, tendon or ligament problems?*YesNo15k. Are you at present having any treatment prescribed by a doctor?*YesNo15l. Renal Condition, HIV or other immuno-suppressive illnesses*YesNo15m. An illness or medical condition that may re-occur*YesNo15n. Tuberculosis*YesNo15o. Bronchitis*YesNo15p. Diabetes*YesNo15q. Dermatitis or other skin disorders*YesNo15r. Varicose veins causing trouble*YesNo15s. Back/Neck trouble, Sciatica/Arthritis*YesNo15t. Heart trouble, Heart Attack or Angina*YesNo15u. Gynaecological Problems*YesNo15v. Psychiatric Disorders, Depression, Stress Related Disorder or Breakdown*YesNo15w. Chemical Sensitivities*YesNo16. In the last two years, have you been off work because of illness or injury?*YesNo17. Do you have, or have you had and defect, disorder, or any other condition, mental or physical not already mentioned in one of your answers?*YesNoYou have answered YES to one or more questions in the above section. Please give more details, including dates, time lost at work and any treatment provided / being provided.* 18. Do you have an electronic cardiac implant (pacemaker) or any other implant that may be affected by electromagnetism?*YesNo19. Will your role require you to drive a company car or vehicle?*YesNo19a. Have you ever had or experienced respiratory or sleep disorders (eg. sleep apnoea)?*YesNo19b. Have you ever had or experienced visual disorders (eg. cataracts, tunnel vision, loss of effective vision in either or both eyes)?*YesNo19c. Have you ever had or experienced cardiovascular disorder or atrial fibrillation?*YesNo19d. Are you taking any regular medication (either prescribed or purchased over the counter)?*YesNo19e. Have you ever been denied a driving license or had your license suspended on health grounds?*YesNo19f. Is it more than two years since you had your eyesight tested by an optician?*YesNo19g. Have you had laser eye surgery?*YesNoYou have answered YES to one or more questions in the above section. Please give more details, including dates, time lost at work and any treatment provided / being provided.* I confirm that all answers given are true to the best of my knowledge. I give Black & Banton Ltd my consent to (a) hold relevant medical information to process my case; (b) computerise my personal and medical information; (c) contact me to arrange appointments and manage my case including linking my medical history to sickness absence data; and (d) use my medical information to provide an assessment of my fitness for work for my employer. I give consent for a summarised report containing relevant clinical information to be released, in the strictest of confidence, to a designated officer within Drager Safety UK Ltd. I consent for Black & Banton to contact either my GP or Occupational Health Unit at my previous employment to discuss any aspect of my health record. The name and contact telephone of my GP or practice is:GP's name or name of practice*GP or practice telephone number* Responses submitted by: Name* First Last PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.