Health Surveillance Questionnaire

Contact Us

Please complete ALL SECTIONS of the following form IN FULL

If you would prefer a printed copy to complete instead please contact us as quickly as possible as not to miss the next pay date.

If there are any changes during the year to any of the details below you must notify us immediately.

Please leave blank:

Your Personal Details

First Name:

Last Name:

Date of Birth:

Mobile number:

Email Address:

Job Title:

Since your last assessment has anything changed regarding your health or job role?

Yes No

If yes give details:

Work Activities

Does your job involve any of the following?

Never

Rarely = Less than 2 hours per week on average

Occasionally = less than 2 hours per day or 8 hours per week on average

Frequently = more than 2 hours per day or 8 hours per week on average

Exposure to wood dust?

Never Rarely Occasionally Frequently

Exposure to stone / cement dust?

Never Rarely Occasionally Frequently

Use of vibrating tools?

Never Rarely Occasionally Frequently

Work in noisy environments?

Never Rarely Occasionally Frequently

Use of hazardous chemicals?

Never Rarely Occasionally Frequently

Repeated exposure to substances on skin? E.g. cleaning products, fillers etc.

Never Rarely Occasionally Frequently

Please use this area to expand on the above answers – list any work processes, tools, chemicals etc. that you think may have an adverse affect on your health.

Do you undertake any work outside of your employment with us? Please provide details.

Respiratory Health

Do you have or have you ever had...

Asthma:

Yes No

COPD:

Yes No

Farmers Lung (caused by mould in straw/hay/animal feeds):

Yes No

Byssinosis (caused by plant/cotton dust):

Yes No

Pneumoconiosis (caused by industrial dust):

Yes No

Bird fanciers lung or do you keep/have you kept birds (Circle):

Yes No

Hayfever:

Yes No

Pulmonary Tuberculosis (TB):

Yes No

Pneumonia:

Yes No

Recurring Bronchitis:

Yes No

An injury or operation affecting your chest:

Yes No

Any other condition affecting the lungs or chest:

Yes No

Have you ever smoked?

Yes No

If yes please state quantity per day:

Do you smoke at present?

Yes No

If yes how long have you smoked for?

Have you given up smoking in the last month?

Yes No Not Applicable

Have you had Covid-19? (suspected or confirmed with positive PCR test):

Yes No

In the last 12 months...

Have you worked in areas where there is a need to use LEV for welding fume?

Yes No

Have you used metal cutting/working fluids (coolant)?

Yes No

If YES, how often?

Have you noticed any new or worsening respiratory changes?

Yes No

Have you had any new chest illness/problems that have kept you from your usual activities for as much as a week?

Yes No

Do you normally produce phlegm on most days for as much as 3 months each year?

Yes No

Do you ever get short of breath when walking on level ground?

Yes No

Do you ever wheeze?

Yes No

Do you usually cough during the day or at night when on night work?

Yes No

Do any respiratory issues improve in periods away from work (on days off or during leave)?

Yes No

If you have answered YES to any of the above, is this unchanged/normal for you?

Yes No

Hearing

Since your last review...

Have you had any new problems with your ears or hearing?

Yes No

Have you suffered from ringing in your ears (tinnitus)?

Yes No

Have you suffered from giddiness or dizziness (vertigo) associated with your ears?

Yes No

Have you suffered from recurring ear infection or discharge from your ears?

Yes No

Have you worn hearing protection?

Yes No

Have you had your hearing tested or seen a hearing specialist other than for the usual hearing screening at work?

Yes No

Have you noticed any new difficulty

Using the telephone?

Yes No

Hearing the television?

Yes No

Are you told you have the TV too loud?

Yes No

Holding a conversation in a crowd?

Yes No

Have your hobbies ever included

Playing a musical instrument?

Yes No

Attending clubs, discos or concerts?

Yes No

Motor Sport or Motor Cycle racing?

Yes No

Shooting?

Yes No

Other noisy activity?

Yes No

Have you ever been exposed to heavy gunfire or explosion?

Yes No

If you have answered YES to any of the questions above please provide details here:

Skin exposure

Since your last review have you had any of the following symptoms?

Redness and swelling of the fingers or hands?

Yes No

Cracking of skin or blisters on fingers or hands?

Yes No

Flaking or scaling or skin on fingers or hands?

Yes No

Itching of fingers or hands with cracks or splits in the skin?

Yes No

Did these problems last for more than 3 weeks?

Yes No

Did these problems occur more than once?

Yes No

Does your skin improve in periods off work (i.e. on leave or days off)?

Yes No

Have you lost time from work with skin problems since last being seen?

Yes No

If present, do you think you know what may be causing any skin problems?

Yes No

Give details:

Since your last assessment, has your exposure to potential skin irritants or sensitisers changed significantly?

Yes No

Do you use barrier cream or moisturiser on your skin when at work or at home?

Yes No

Have you been diagnosed with/do you have Eczema, Psoriasis, Dermatitis or any other skin condition which is normal for you?

Yes No

Vibration at Work

Have you been using hand-held vibrating tools, machines or hand-fed processes in your job?

Yes No

If answered NO there is no need to answer any further questions in this section

Your General Health

Have you been diagnosed with or suffered from any of the following?

Heart or circulatory problems inc. high blood pressure or blood clots:

Yes No

Give details:

Fainting, dizzy spells, vertigo or any disorder affecting your balance:

Yes No

Give details:

Illness of the lungs (asthma, bronchitis, COPD etc):

Yes No

Give details:

Neurological disorder such as Epilepsy, Seizures or Stroke:

Yes No

Give details:

Diabetes:

Yes No

Give details:

Musculoskeletal problems inc. back, arms, shoulders, any other joints:

Yes No

Give details:

Any weakness of your limbs:

Yes No

Give details:

Skin conditions (eczema, dermatitis, psoriasis):

Yes No

Give details:

Disease of or surgery on the ears:

Yes No

Give details:

Disease of or surgery on the eyes or any visual disturbances:

Yes No

Give details:

Psychiatric illness inc. anxiety, depression, Bi-Polar:

Yes No

Give details:

Difficulties with your concentration or memory:

Yes No

Give details:

Sleep disorders inc. sleep apnoea:

Yes No

Give details:

Operations or serious accident needing hospital treatment:

Yes No

Give details:

Addiction to alcohol or drugs:

Yes No

Give details:

Are you taking any medication (prescribed or bought):

Yes No

Give details:

Lifestyle

Do you drink alcohol?

Yes No

If yes, what and how much per week?

Exercise and Hobbies:

Weight:

Height:

Additional Comments

Please use this space to provide any additional information you feel is relevant to this assessment.

Declaration

I declare that the information provided above is, to the best of my knowledge and belief, true and complete.

I understand that the information I have provided will be used by my employer to assess my fitness to undertake my role for statutory health surveillance purposes, and to contribute towards the wider company occupational health risk assessment.

I accept the above information will be held in the guardianship of my current employer and forms part of my occupational health record and this will be retained for as long as I work for my current employer and in accordance with current legislations and includes the Data Protection Act and the General Data Protection Regulations (2018)

Your Name:

Date: