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SECTION B – CANDIDATE INFORMATION

Are you currently employed with the employer? If yes, please tick where appropriate.
Current Employer
Contractor
Employment Agency

Yes
NO

If not currently employed by the employer, have you ever worked for the employer previously?

Yes
NO

Do you currently have any work restrictions certified by a doctor?
If yes, please give details:

Yes
NO

OCCUPATIONAL HISTORY (current & previous – up to 3 years)

Employer

Type of Job

Dates :
From-To

Occupational Noise Exposure:
Yes/No

Yes
NO

Yes
NO

Yes
NO

No
Have you ever had:
Yes/No
If YES provide any relevant details
1
Do you, or have you, taken any regular medication including over the counter or vitamins. If yes, please state medications
Yes     No
2
To work with any substances or in any conditions that may be hazardous to your health? eg asbestos exposure, toxic chemicals
Yes     No
3
Noise exposure? If Yes, was hearing protection used?
Yes     No
4
To perform repetitious work?
Yes     No
5
Silicosis, asbestosis or mining lung problems?
Yes     No
6
Allergic reactions to any food, pollens, grasses or stings?
Yes     No
7
Allergy to rubber, rubber bands or string?
Yes     No
8
Any skin condition affecting the hands or feet?
Yes     No
9
Asthma or shortness of breath?
Yes     No
10
Bronchitis, chest infections, persistent cough, TB, or other lung problems?
Yes     No
11
Chest pain – heart problems, heart beating too fast or slow or irregular?
Yes     No
12
Rheumatic fever or heart murmur?
Yes     No
13
High or low blood pressure?
Yes     No
14
Hay fever, sinus trouble?
Yes     No
15
Hearing or other ear problems such as ringing in the ears or tinnitus?
Yes     No
16
Bad indigestion, reflux or difficulty swallowing?
Yes     No
17
Problems with taste or smell?
Yes     No
18
Sleep disorder or sleep apnoea?
Yes     No
19
Frequent heartburn, ulcers or pancreatitis?
Yes     No
20
Any hernia – inguinal, abdominal?
Yes     No
21
Abdominal pain or persistent vomiting?
Yes     No
22
Weakness, anaemia, blood disorder, recurrent or severe infections?
Yes     No
23
Varicose veins, blood clots or poor circulation?
Yes     No
24
Skin disorders- e.g. rashes, psoriasis, dermatitis or eczema?
Yes     No
25
Trouble with eyes or seeing? Example: colour-blindness
Yes     No
26
Difficulty with speech or speaking?
Yes     No
27
Blackouts, giddiness, epilepsy, fits or ‘funny turns’?
Yes     No
28
Dizzy spells, fainting or attacks of unconsciousness?
Yes     No
29
Numbness or weakness in face, arms hands or legs? Clumsiness or lack co-ordination?
Yes     No
30
Migraines, bad headaches or head injuries??
Yes     No
31
Stroke or temporary stroke attacks?
Yes     No
32
Anxiety, depression, neurological/nervous or mental disorder?
Yes     No
33
Mental Illness such as Schizophrenia or Bipolar Disorder
Yes     No
34
Hepatitis or liver problems?
Yes     No
35
Conflict or stress at work that required medical treatment or counselling?
Yes     No
36
Urinary tract, kidney or prostate problems?
Yes     No
37
Cancer or tumour of any type?
Yes     No
38
Diabetes? Type?
Yes     No
39
Thyroid problems?
Yes     No
40
Infectious disease (i.e. Hepatitis A/B/C or HIV)?
Yes     No
41
Arthritis, joint disorders, joint injury or pain?
Yes     No
42
Elbow or wrist problems- i.e. Tennis elbow, ‘RSI’, carpel tunnel, tendonitis, a ganglion?
Yes     No
43
Shoulder pain, tendonitis or frozen shoulder?
Yes     No
44
Foot, leg, hip, knee, or ankle problems? Arthritis, gout, sciatica pain?
Yes     No
45
Any broken bones (fractures)? Where?
Yes     No
46
A limb deformity or have you had a limb or extremity amputated?
Yes     No
47
Any back pain? Any back x rays, scans or ultrasounds taken?
Yes     No
48
Orthotics presently or in the past?
Yes     No
49
Any neck pain, stiff neck or whiplash? Any neck x-rays, scans or ultrasound taken?
Yes     No
50
Any treatment on back or neck?
Yes     No
51
Chronic fatigue? Lasting more than six weeks
Yes     No
52
Drug or Alcohol problems?
Yes     No
53
Do you smoke or have you ever smoked? If Yes, how many/often?
Yes     No
54
Do you drink alcohol?
Yes     No
55
Have you consulted a physiotherapist, chiropractor, or osteopath? If Yes, why and what was the condition?
Yes     No
56
Any admissions to hospital for any reason such as an injury or operation? If Yes please list
Yes     No
57
Any serious illnesses? If yes, include details of illness & treating doctor
Yes     No
58
Any injuries in a motor vehicle accident? If yes, please specify
Yes     No
59
Do you currently hold a conditional drivers licence (a licence with restrictions due to a medical condition)? If yes, give details
Yes     No
60
Do you have any condition’s that you should report to your relevant State or Territory drivers licence authority: If yes, please specify
Yes     No
61
Any sporting injuries?
Yes     No
62
Which is your dominant hand?
Left     Right
63
Any family history of medical conditions?
Yes     No
64
How often do you exercise? What type of exercise do you do? For how long do you exercise?
Yes     No
65
Do you play sport? If yes, what sport do you play and how often?
Yes     No
66
Do you, or have you, taken any regular medication including over the counter or vitamins. If yes, please state medications
Yes     No
67
Will you be required to take any regular medication during this employment? If yes, please state medications
Yes     No
68
Have you ever been refused or deferred for Life Insurance or Superannuation: If yes, please give details
Yes     No
69
Have you had any previous workers compensation claims at all? If yes, provide dates, claim number and injury details
Yes     No
70
Are any of these pending? If yes, provide details and claim number
Yes     No
71
When was your last tetanus injection?
Yes     No
72
Crouching / bending / kneeling?
Yes     No
73
Squatting, climbing or reaching above shoulder height?
Yes     No
74
Walking 4 km in one hour (steady walk)?
Yes     No
75
Walking 6 km in one hour (brisk)?
Yes     No
76
Running 100 metres?
Yes     No
77
Walking on uneven ground?
Yes     No
78
Concentrating on a task?
Yes     No
79
Standing for up to eight hours or more a day (with routine rest breaks)?
Yes     No
80
Sitting for 2 hours or more?
Yes     No
81
Understanding English (including reading)
Yes     No
82
Repetitive movement of hands or arms
Yes     No
83
Gripping with both hands
Yes     No
84
Fears or phobias. Example: to travel, confined spaces?
Yes     No
85
Wearing any Personal Protective Equipment such as safety shoes/boots, glasses, helmets etc
Yes     No
86
Climbing stairs or ladders or with heights
Yes     No
87
Working in hot/cold extremes
Yes     No
88
Shift work / sleep
Yes     No
89
Do you have any other disorders or dysfunctions not previously mentioned? If yes, provide details
Yes     No
In the past 4 weeks, about how often did you feel tired out for no good reason?:
none of the time
a little of the time
some of the time
most of the time
all the time
In the past 4 weeks, about how often did you feel
none of the time
a little of the time
some of the time
most of the time
all the time
In the past 4 weeks, about how often did you feel so nervous that nothing could calm you down?
none of the time
a little of the time
some of the time
most of the time
all the time
In the past 4 weeks, about how often did you feel hopeless?
none of the time
a little of the time
some of the time
most of the time
all the time
In the past 4 weeks, about how often did you feel restless or fidgety?
none of the time
a little of the time
some of the time
most of the time
all the time
In the past 4 weeks, about how often did you feel so restless you could not sit still?
none of the time
a little of the time
some of the time
most of the time
all the time
In the past 4 weeks, about how often did you feel depressed?
none of the time
a little of the time
some of the time
most of the time
all the time
In the past 4 weeks, about how often did you feel that everything is an effort?
none of the time
a little of the time
some of the time
most of the time
all the time
InIn the past 4 weeks, about how often did you feel so sad that nothing could cheer you up?
none of the time
a little of the time
some of the time
most of the time
all the time
In the past 4 weeks, about how often did you feel worthless?
none of the time
a little of the time
some of the time
most of the time
all the time
Are you familiar with the essential requirements of the job for which you are applying?
Yes
No
Have you ever been refused employment due to the state of your health?
Yes
No
If yes, please specify reason and approximate date:
Reason
Year
Do you have any medical condition not mentioned in the above questions which, to your knowledge, may result in you being unable to safely carry out the duties of the position applied for?
If yes, please specify:
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