Medical Questionaire

* Indicates required field

Name *

Please answer the following questions regarding your Medical History

Have you ever had a work related injury? *

Yes No

Have you ever lodged a Workers Compensation claim? *

Yes No

Have you ever had a sporting injury? *

Yes No

Are you currently being treated by a Doctor? *

Yes No

Have you ever been hospitalised for any illness or had any operations? *

Yes No

Have you ever been refused life insurance, disability insurance, employment or military service? *

Yes No

Is there any reason why you cannot wear safety or protective equipment? *

Yes No

Have you ever tested positive in any workplace drug or alcohol screening test? *

Yes No

Are you taking any medication? *

Yes No

Is there any family history of medical conditions? *

Yes No

Do you wear glasses for normal work? *

Yes No

If so do you have prescription safety glasses? *

Yes No

Do you have any difficulties with the following activities?

Running 100 Metres *

Yes No

Walking on rough ground *

Yes No

Turning your head rapidly *

Yes No

Using hand tools *

Yes No

Concentrating for any length of time *

Yes No

Hearing a normal conversation *

Yes No

Reading ordinary print *

Yes No

Climbing a ladder *

Yes No

Crouching *

Yes No

Lifting or bending *

Yes No

Gripping firmly with both hands *

Yes No

Repetitive movement of the arms *

Yes No

Repetitive movement of the head *

Yes No

Understanding English *

Yes No

Do you have or have you had any of the following?

Lung problems/asthma/bronchitis *

Yes No

Suffered blood pressure or hearth problems *

Yes No

Repetitive strain/overuse injuries *

Yes No

Joint problems/fractures or arthritis/rheumatism *

Yes No

Back or neck problems *

Yes No

Skin disorders/dermatitis *

Yes No

Blackouts or persistent headaches *

Yes No

Mental or nervous problems *

Yes No

Loss of hearing/ear infections *

Yes No

Stomach problems/ulcers *

Yes No

A hernia *

Yes No

Fits or seizures *

Yes No

Allergies *

Yes No

Any medical or surgical issues *

Yes No

Time of work in the last year *

Yes No

Diabetes *

Yes No

Tuberculosis *

Yes No

Hepatitis/Jaundice/Live Trouble *

Yes No

If answered 'YES' to any of the above please give details below *

For ANY past injury, work related or personal (sporting etc) please provide details below

Details of first injury

is this a work related Injury? *

Yes No

Nature of injury *

Date of injury *

Name of Employer *

Number of days off *

Details of second injury

Nature of injury *

Date of injury *

name of employer *

Number of days off *

All the information I have given in the Medical Questionnaire is true and accurate *

Yes

See below terms and conditions

I have read and agree to the Ultimate Recruitment Terms and Conditions *

Yes

Submit