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Health Questionnaire
Personal Details
*
First Name
*
Last Name
*
Email
*
Closest GOAL Office
-
NSW Broken Hill
NSW Newcastle
NSW Singleton
NSW Sydney
NT Darwin
QLD Brisbane
QLD Gladstone
QLD Townsville
SA Adelaide
TAS Hobart
TAS Launceston
VIC Melbourne
WA Perth
Have you had or do you have any of the following?
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Work related injury or illness
Yes
No
*
Current injury or illness
Yes
No
*
A Workers Compensation claim
Yes
No
*
High blood pressure
Yes
No
*
Diabetes
Yes
No
*
Cardiovascular problems - stroke, heart attack, angina
Yes
No
*
Respiratory problems – emphysema, asthma
Yes
No
*
Liver disease - hepatitis, jaundice
Yes
No
*
Kidney problems
Yes
No
*
Cancer or tumours
Yes
No
*
Stomach problems - ulcer, hernia
Yes
No
*
Back pain/problems
Yes
No
*
Repetitive use or strain injury
Yes
No
*
Joint problems - arthritis, rheumatism
Yes
No
*
Bone fractures
Yes
No
*
Neck or shoulder pain/problems
Yes
No
*
Knee pain/problems
Yes
No
*
Any other musculoskeletal issues
Yes
No
*
Sporting injury
Yes
No
*
Been refused life insurance
Yes
No
*
Mental Illness
Yes
No
If you answered yes to any of the above, please provide further details below:
Do you have difficulty with any of the below?
*
Walking on rough ground
Yes
No
*
Concentrating for any length of time
Yes
No
*
Running 100 meters
Yes
No
*
Hearing a normal conversation
Yes
No
*
Sitting or standing for two hours
Yes
No
*
Wearing PPE
Yes
No
*
Turning your head rapidly
Yes
No
*
Climbing a ladder
Yes
No
*
Using hand tools
Yes
No
*
With claustrophobia
Yes
No
*
Lifting
Yes
No
*
Repetitive moving of the arms
Yes
No
*
Reading & writing English
Yes
No
*
Squatting or kneeling
Yes
No
*
Twisting or bending
Yes
No
*
Understanding any of these questions
Yes
No
*
Sleeping
Yes
No
*
With heights
Yes
No
If you answered yes to any of these, please provide further details below:
Medical History
*
Is there any other medical history, issues or concerns not listed above?
Yes
No
If you answered yes, please provide details
*
Are you currently taking any medication not listed above?
Yes
No
If you answered yes, please provide details
*
Do you have any allergies?
Yes
No
If you answered yes, please provide details
Who is your regular GP in case of an emergency?
Name
Clinic
Address
Phone
Declaration
*
I confirm that all information provide is correct at the time of submitting this form. I also have read and understood GOAL's
Privacy Policy
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