Occupational Health Questionnaire for Volunteers Confidential
Please complete this form, seal this form and the Occupational Health Fitness Form in a seperate envelope addressed to Occupational Health Dept, and return it with the MDR Application form.
1	Personal Details
a.	Dr / Mr / Miss / Ms / Other (please specify)				Male / Female
	Surname …………………………			First Name ……………………….
	Previous surname (where applicable) ……………………………………..
	Date of birth …/..…./…...
	Current address ……………………………………………………………………
		………………………………………………Post Code ……………………..
	Telephone Number …………………………………………………………………
b.	Do you consider yourself to have a disability?					Yes / No
	If yes please describe ………………………………………………………………
	Disability (As described by the Disability Discrimination Act 1995)-
	"a person has a disability if he/she has a physical or mental impairment
	which has a substantial and long-term adverse effect on his/her ability to
	carry out normal day-to-day activities which is likely to last at least
	12 months, or is likely to last for the rest of that persons life."
	The question is asked to enable us to identify what adjustments to the
	working environment may be necessary to help you fulfil the role and/or
	to work safely.
2	Health History
a.	Have you had any operations, treatment, investigations/ or tests in the
	past 24 months? Yes/No
	Please give details ……………………………………………………………
b.	Are you awaiting any operations, treatment, investigations or tests?
	Yes/No
	Please give details ……………………………………………………………
c.	Are you taking any pills, tablets, medicines or inhalers or having any
	treatment? Yes/No
	Please give details …………………………………………………………………………………….
d.	Are you, or have you ever been, drug, alcohol or any substance
	Dependent - inc. cigarettes/tobacco? Yes/No
	Please give details …………………………………………………………………………………………………
e.	Do you have or have you ever had any of the following?
	(As far as you can remember)
			Yes	No	Details
	Any Medical Condition				………………………………………………….
	Musculoskeletal problems				………………………………………………….
	Back Problems				………………………………………………….
	Any Joint problems				………………………………………………….
	Skin Problems				………………………………………………….
	Eating disorders				………………………………………………….
	Nervous Problems				………………………………………………….
	Mental Health problems				………………………………………………….
	Epilepsy/ Fits/ Blackouts				………………………………………………….
	Allergies/ allergic reaction				…………………………………………………..
	Diabetes				…………………………………………………..
	Respiratory Problems				…………………………………………………..
	Difficulty seeing that cannot be corrected by glasses or contact lenses?
					Yes/No
	Please give details …………………………………………………………………………………………….
3	Vaccination Status and Infectious Diseases
	(As far as you can remember)				Yes		No	Date
a.	Have you ever had chicken pox?				………….		………….	………….
	Have you been vaccinated against:
b.	Tuberculosis (BCG)				………….		………….	………….
c.	If yes, do you have a characteristic scar				………….		………….	………….
d.	Have you ever been tested for TB				………….		………….	………….
e.	Rubella/ German Measles (Result Needed)				………….		………….	………….
f.	Hepatitis B (Please give result of blood test)				………….		………….	………….
g.	Have you travelled or lived abroad for the past year for a period of one
	month or more? Yes/No
	If so what countries? ………………………………………………………………………………………….
	Do you suffer from any of the following symptoms?
	Please circle if yes
	UNEXPLAINED fatigue, fever, high temperature, night sweats or
	loss of weight/ coughing, or coughing up sputum/blood or phlegm
	for more then 3 consecutive weeks.
	Please give any additional health information you may wish to add, continue on a separate sheet if needed.
	……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………
	OCCUPATIONAL HEALTH AGREEMENT FORM
	I declare that the answers and statements on this document are complete
	and accurate and that I will inform the Volunteers Services Manager of
	any changes in my health or any other circumstances that may affect my
	voluntary work within the Trust.
	I understand that I may be required to attend the Occupational Health
	Department and that all health and medical information is treated in the
	strictest confidence.