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Medical Questionnaire
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First Name
*
Last Name
*
Email
Key Information
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Have you ever had a work related injury?
Yes
No
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Have you ever had a sporting injury
Yes
No
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Have you ever lodged a Workers Compensation claim?
Yes
No
If yes, please detail with dates
*
Are you currently being treated by a doctor?
Yes
No
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Have you ever been hospitalised for any illness or had any operations?
Yes
No
If yes, please detail
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Time off work in the last year?
Yes
No
If yes, please detail with dates
Additional Information
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Have you had to wear a face mask due to Working with Respirable Crystalline Silica (RSC) Dust
Yes
No
If yes, when did you get fit tested?
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Have you had the medical to monitor exposure to Respirable Crystalline Silica (RSC) Dust
Yes
No
If yes, please detail.
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Have you ever been refused life insurance, disability insurance, employment or military service?
Yes
No
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Is there any reason why you cannot wear safety or protective equipment?
Yes
No
If yes, please detail
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Have you ever tested positive in any workplace drug or alcoholic screening test?
Yes
No
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Are you taking any medication?
Yes
No
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Is there any family history of medical conditions?
Yes
No
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Do you wear glasses or normal work?
Yes
No
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If so do you have prescription safety glasses?
Yes
No
Do you have any difficulties with the following activities?
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Running 100 Meters
Yes
No
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Walking on rough ground
Yes
No
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Turning your head rapidly
Yes
No
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Using hand tools
Yes
No
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Concentrating for any length of time
Yes
No
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Hearing a normal conversation
Yes
No
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Reading ordinary print
Yes
No
*
Climbing a ladder
Yes
No
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Crouching
Yes
No
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Lifting or bending
Yes
No
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Gripping firmly with both hand
Yes
No
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Repetitive movement of the arms
Yes
No
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Repetitive movement of the head
Yes
No
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Understanding English
Yes
No
Do you have or have you had any of the following?
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Lung problems/asthma/bronchitis
Yes
No
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Suffered blood pressure or heart problems
Yes
No
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Joint problems/fractures or arthritis/rheumatism
Yes
No
*
Repetitive strain/overruns
Yes
No
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Mental or nervous problems
Yes
No
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Blackout or persistent headaches
Yes
No
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Stomach problems/ulcers
Yes
No
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Loss of hearing/ear infections
Yes
No
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Fits or seizures
Yes
No
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A hernia
Yes
No
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Diabetes
Yes
No
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Allergies
Yes
No
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Hepatitis/Jaundice/Liver Trouble
Yes
No
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Tuberculosis
Yes
No
Confirmation of Information
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All the information I have given in the Medical Questionnaire is true and accurate
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