Occupational Health History

#Occupational Health History (pre-employment/pre-placement) Current job (or job applied for): 1. MEDICAL HISTORY: Do you have, or have you EVER had: (-) High blood pressure, heart attack, angina, palpitations, coronary artery bypass graft, coronary artery stent, heart failure, varicose veins or other heart condition? (-) Depression, anxiety state or psychiatric/ psychological condition? (-) Problems with environments or spaces such as: small spaces, cramped spaces, crowds, noise, dust, or odours? (-) Alcohol or drug abuse or dependence? (-) Epileptic fits, fainting, dizzy spells, migraine, stroke, head injury, brain surgery or other neurological condition? (-) Inflammatory bowel disease, jaundice, hepatitis, peptic ulcer, abdominal surgery (including laparoscopic surgery) or hernia (rupture)? (-) Asthma, bronchitis, emphysema, persistent cough, shortness of breath or problems wearing face masks? (-) Kidney disease or kidney stones? (-) Back pain, sciatica, slipped disc, neck problems? (-) Arthritis, stiff joints, swollen joints, joint injuries? (-) Repetitive strain injuries, carpal tunnel, syndrome, tennis elbow, tendonitis? (-) Hearing problems, ringing in ears, disturbance of balance, use of hearing aid? (-) Diabetes, thyroid problem or any other endocrine problem? (-) Skin cancer, psoriasis, dermatitis or eczema? (-) Eye problems including the need to wear glasses or contact lenses? (-) Allergies or any reactions to chemicals, medicines, vaccines or other substances? (-) Any other complaint, illness or injury which has affected your ability to work in the past for more than two weeks in any year? (-) Are you taking any drugs or medicines, prescribed or otherwise? For example, antihistamines, antidepressants, some blood pressure medications, insulin, puffers, nasal sprays, cannabis, etc? (-) Are you currently unwell or have you been unwell in any way in the last four weeks? (-) Are you aware of ANY health problem that could affect your ability to safely and effectively perform the inherent requirements (functions) of this job (or assignment) or could be made worse by doing so? (-) Have you ever been advised to change jobs or avoid certain types of work because of a medical condition? (-) Do you have additional comments about your suitability or fitness for the job (or assignment) you have applied for (or are currently doing)? Comments on any (+) responses: 2. EMPLOYMENT HISTORY: (Include any military service) Jobs/occupations: Exposures: (-) Noise (-) Dust (-) Radiation (-) Other/s -> Work-related injuries/problems: Comments:

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