Medical Form


SECTION 1 - CONTACT DETAILS




SECTION 2 – MEDICAL HISTORY


YesNo


YesNo


YesNo



YesNo



YesNo



YesNo



YesNo



YesNo



YesNo



YesNo




YesNo


SECTION 3 – EYESIGHT


YesNo

DistanceDrivingReadingComputer Work

YesNo

DistanceDrivingReadingComputer Work

YesNo



SECTION 4 – HEARING


YesNo



YesNo


YesNo



YesNo



YesNo


SECTION 5 – RESPIRATORY


Asthma/Bronchitis/Cough/EmphysemaBreathlessness?Early morning cough/phlegm?Wheezing/Shortness of breath?Chest Tightness?



YesNo



YesNo



YesNo


SECTION 6 – MUSCULOSKELETAL


Arthritis, anywhereProlapsed disc in your back or neck?Surgery to your back or neck?Unstable or painful jointsHad a joint replacement?



YesNo



YesNo


SECTION 7 – PHYSCHOLOGICAL WELLBEING


Poor ConcentrationFeeling of worthlessnessLoss of interestLoss of appetite/weightDepressed mood/sadnessLack of energy/fatigueSleep disturbanceSuicidal thoughts

SECTION 8 - DRUGS AND ALCOHOL


YesNo



YesNo


Rorcon has a Zero tolerance Drug & Alcohol policy for anyone in our workplaces & those managed by our clients. Many of our Clients operate Random Drug & Alcohol Testing. This means that you may be asked to undertake a test at any time at work - Refusal to cooperate with a testing request will result in your immediate suspension from the workplace until you are tested. If you should fail an initial test, you will be asked to leave site & be suspended pending the outcome of a follow up test.

Once the results of a second test are available, should the follow up test be positive (i.e. showing the presence of drugs and/or alcohol), as a minimum, you may receive a written warning & guidance based on the results, but the more likely scenario is that you will be immediately dismissed from our employment for a “serious breach of your employment contract”.

DECLARATION:

I declare that the information given on this form is true and to the best of my knowledge. I further declare that I have not omitted or falsified any facts or details that could have a bearing on my state of health

I will notify my Manager if I develop any of the above conditions in the future. I declare that I have been advised regarding the purpose of this health assessment, and agree to take part.

If you have an accident at work, however, minor you may consider it, you must record it in the accident book or sheet immediately. You must provide details of the nature of the accident or injury, any first aid treatment that was administered, the names of any witnesses and the date and time and place of the accident.

In signing this form, you confirm your explicit consent within the meaning of GDPR (General Data Protection Regulation) for Rorcon to process and store your personal information. If at any time you wish to have access to your Medical Questionnaire you may do so by requesting this in writing.


YesNo