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SECTION C – MEDICAL QUESTIONNAIRE

This online form is to be filled out only by the candidate who is applying for the position

No.
Have you ever had:
Yes/No
If YES provide any relevant details
1
Asthma or shortness of breath?
Yes     No
2
Exposure to dust, asbestos, chemicals? If yes, please list.
Yes     No
3
Was there Repetitious work or noise Exposure?
Yes     No
If noise exposure, was hearing protection used?
Yes No
4
Allergic reactions to anything?
Yes     No
5
Bronchitis, chest infections, persistent cough, TB, or other lung problems?
Yes     No
6
Chest pain – heart problems, heart beating too fast or slow or irregular?
Yes     No
7
High or low blood pressure?
Yes     No
8
Hay fever, sinus trouble?
Yes     No
9
Hearing or other ear problems?
Yes     No
10
Bad indigestion, reflux or difficulty swallowing?
Yes     No
11
Any hernia – inguinal, abdominal?
Yes     No
12
Abdominal pain or persistent vomiting?
Yes     No
13
Weakness, anaemia, blood disorder, recurrent or severe infections?
Yes     No
14
Persistent diarrhoea, bleeding or any bowel disorder?
Yes     No
15
Varicose veins or poor circulation?
Yes     No
16
Skin disorders- e.g. dermatitis or eczema?
Yes     No
17
Trouble with eyes or seeing?
Yes     No
18
Difficulty with speech or speaking?
Yes     No
19
Blackouts, giddiness, epilepsy, fits or faints or ‘funny turns’?
Yes     No
20
Numbness or weakness in face, arms or legs? Clumsiness or lack co-ordination?
Yes     No
21
Migraines or bad headaches?
Yes     No
22
Anxiety, depression, neurological/nervous or mental disorder?
Yes     No
23
Hepatitis or liver disease?
Yes     No
24
Urinary tract or kidney problems?
Yes     No
25
Diabetes? Type?
Yes     No
26
Thyroid problems?
Yes     No
27
Infectious disease (i.e. Hepatitis A/B/C or HIV)?
Yes     No
28
Aches, pain, arthritis, joint disorders, joint injury or pain?
Yes     No
29
Shoulder, elbow or wrist problems- i.e. Tennis elbow, ‘RSI’, carpel tunnel?
Yes     No
30
Foot, leg, hip, knee, or ankle problems? Arthritis, gout?
Yes     No
31
Any operations (surgery) or procedures?
Yes     No
32
Any broken bones (fractures)? Where?
Yes     No
33
Any back pain or neck pain? Any back or neck x rays taken?
Yes     No
34
Do you smoke or have you ever smoked?
Yes     No
35
Do you drink alcohol?
Yes     No
36
Have you consulted a physiotherapist, chiropractor, or osteopath?
Yes     No
37
Any admissions to hospital?
Yes     No
38
Any serious illnesses?
Yes     No
39
Any injuries in a motor vehicle accident?
Yes     No
40
Any sporting injuries?
Yes     No
41
Any family history of medical conditions?
Yes     No
General questions:
Yes/No
If YES include details
42
How often do you exercise? What type of exercise do you do? For how long do you exercise?
Yes     No
43
Do you play sport?
Yes     No
44
Do you, or have you, taken any regular medication? Will you be required to take any regular medication during this employment?
Yes     No
45
Have you ever been refused or deferred for Life Insurance or Superannuation?
Yes     No
46
Have you had any previous workers compensation claims at all? Are any of these pending?
Yes     No
47
Have you had a tetanus injection in the last 5 years?
Yes     No
Do you have difficulty with any of the following activities:
Yes/No
If YES provide any relevant details
48
Crouching / bending / kneeling
Yes     No
49
Running 100 metres
Yes     No
50
Walking on uneven ground
Yes     No
51
Turning your head rapidly
Yes     No
52
Concentrating on a task
Yes     No
53
Standing for 2 hours or more
Yes     No
54
Sitting for 2 hours or more
Yes     No
55
Climbing stairs
Yes     No
56
Understanding English (including reading)
Yes     No
57
Repetitive movement of hands or arms
Yes     No
58
Do you have any other disorders or dysfunctions not previously mentioned?
Yes     No
These questions are specific to the job you have applied for. Do you have any difficulty with:
Yes/No
If YES provide any relevant details
59
Wearing any Personal Protective Equipment?
Yes     No
Not Applicable
60
Climbing ladders
Yes     No
Not Applicable
61
Working at heights
Yes     No
Not Applicable
62
Working in hot/cold extremes
Yes     No
Not Applicable
63
Shift work / sleep
Yes     No
Not Applicable
64
Gripping with both hands
Yes     No
Not Applicable
65
Confined spaces
Yes     No
Not Applicable
66
Using hand tools
Yes     No
Not Applicable

If more details are required for any of the above please provide information below: (include Reference Question No.)

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