Medical History Questionnaire

MEDICAL HISTORY
QUESTIONNAIRE

CONFIDENTIAL (WHEN COMPLETED)

MEDICAL HISTORY
QUESTIONNAIRE

For official use only
Candidate number

CONFIDENTIAL (WHEN COMPLETED)

Our health standard requires you to show that you can give reqular and effective service. In order to do this, we ask you to provide details of your health. Do not be concerned if you find yourself answering ‘Yes’ to a lot of questions. This is quite normal and does not mean that you are unfit for the job. We will contact you if we need further details and, if necessary, ask for a report from your GP. The health of each candidate is considered individually and no decision to reject a candidate is made without referral to a medical advisor.

If you successfully pass the assessment centre stage of the recruitment process, you will be asked to complete this form and take it to your GP for confirmation. Once your GP has signed the form, send it to the occupational health unit of the force you are applying to in the envelope supplied. Please keep a copy of your form.

You will then be invited to attend a medical examination or referred to your GP for a medical examination.

The information given on this form and at subsequent medical examinations will also be used to form an opinion of whether you are at risk of early ill-health retirement. If you do not wish to know the outcome of that assessment you can ask for it to be withheld unless you subsequently decide to appeal against the decision.

Please note that you will be required to sign a declaration at the end of this form and it is important that your answers are accurate and you do not withhold any information. We are an equal opportunities employer and recruit on the basis of ability not perceived disability. Any information given on your medical history on any disability will assist us in assessing whether reasonable adjustments can be made.

Your details
Surname:	Forename(s):
Date of birth:	Male / female (delete as appropriate):
Full postal address including postcode:

Telephone:

General Practitioner’s Details
Name:	Telephone Number:
Full postal address including postcode:

Please answer ALL the following questions. If you answer YES to any of the conditions, you will need to give details on page 5 including the appropriate medical condition number. If you have any questions, contact your local recruitment office for advice or for referral to the Occupational Health Unit.

The Disability Discrimination Act 1995 defines a person with a disability as “A physical or mental impairment which has a substantial adverse long term effect on his or her ability to carry out normal day to day activities.”

Do you have a disability which may affect your ability to undertake the role of police constable or which requires special arrangements?

Yes

If yes, what facilities/adjustments/equipment might enable you to perform the role?

Medical Conditions

You are asked to indicate whether you currently have or have ever had any of the following medical conditions.

Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness

Yes

Head injuries leading to loss of consciousness requiring hospital admission

Yes

Recurrent headache or migraine

Yes

Diseases of the nervous system e.g. neuritis, stroke, multiple sclerosis

Yes

Injury or surgery to your eye(s) including laser eye surgery or any other type of refractive surgery

Yes

Any visual defect e.g. scotoma, blindness in one eye, night blindness, colour blindness, reduced visual field, blurred vision or detached retina

Yes

Any eye disease or conditions such as glaucoma or retinitis pigmentosa

Yes

Ear infection, discharge, tinnitus, a hearing defect including deafness

Yes

Vertigo, dizziness, giddiness, problems with balance

Yes

Chest pain, angina, heart disease or breathlessness

Yes

Varicose veins or circulation problems

Yes

Rheumatic fever

Yes

Raised or low blood pressure

Yes

Any blood disorder

Yes

Asthma, bronchitis, emphysema, pleurisy, pneumonia or any other lung disease including TB or pneumothorax disorder

Yes

Recurrent nausea, dyspepsia, heartburn, indigestion or hiatus hernia

Yes

Gastric, duodenal or peptic ulcer

Yes

Inflammation of the bowel including Crohn’s Disease, ulcerative colitis, bleeding from rectum or diarrhoea lasting more than one week

Yes

Irritable bowel syndrome

Yes

Medical Conditions

Jaundice or any form of hepatitis or other liver problem

Yes

Any other abdominal complaint including hernia

Yes

Kidney stones

Yes

Recurrent kidney or urinary tract infection e.g. cystitis and urethritis

Yes

Blood in urine

Yes

Any other kidney or bladder conditions

Yes

Any problems with bones or joints including back, neck, knee, sciatica, any fracture, or recurrent dislocation of a major joint

Yes

Have you ever consulted an orthopaedic surgeon, chiropractor, osteopath or physiotherapist?

Yes

Have you been diagnosed as having arthritis, gout, chondromalcia patellae or rheumatism?

Yes

Psoriasis, eczema, allergic skin rash or other skin disease

Yes

Any metabolic disorder including diabetes, thyroid and adrenal gland disease or other glandular disorder

Yes

Any disorders of reproductive organs including gynaecological, testicular and breast problems

Yes

Any infectious diseases (apart from childhood illnesses) including sexually transmitted disease or tropical disease

Yes

Anxiety/depression, phobias, mental breakdown or stress related problems

Yes

Any other mental illness

Yes

Any eating disorder e.g. anorexia nervosa or bulimia

Yes

Substance misuse (e.g. drugs, steroids)

Yes

Any allergies including hayfever

Yes

Any operations or surgical procedures

Yes

Any malignancies or cancers

Yes

Any unexplained weight loss in past year

Yes

Current treatment. Are you currently attending a hospital/GP for treatment or waiting for an appointment?

Yes

If you have ticked ‘Yes’ to any of the above, please give details in the space provided on page 5. This will help the Occupational Health Unit to clarify the significance or otherwise of a ‘Yes’ answer. Please ensure that you quote the correct medical condition number.

Details of Medical Conditions
Please include date(s) of illness/conditions, frequency, duration, what treatment was given and by whom (e.g. hospital/GP), whether you are still undergoing treatment and length of absence from work/school (if appropriate). Continue on a separate sheet if required.
Medical Condition Number (see table on pages 3 and 4)	Details

Family History

Is there a family history of a congenital condition (e.g. heart disease, strokes, nervous or mental disease)? If YES please give details and relationship

Height (metres)	Weight (kgs)

Alcohol History

How much alcohol on average do you consume over a seven day period?
Units per week 1 unit = 1/2 pint beer = 1 glass of wine = 1 measure of spirits

Past Medical History

Have you ever failed a medical examination (or had special conditions imposed) for any employment reasons (including police service and HM Forces) or life assurance? If YES, please provide details.

Yes

Have you previously been notified that you would not be eligible for ill health benefits if appointed to the police service? If YES, please provide details.

Yes

Have you ever left a job or had to be medically retired due to ill health? If YES, please provide details.

Yes

Has any previous occupation caused you health problems? If YES, please provide details.

Yes

Are you in receipt of a medical pension or other disability benefit? If YES, please provide details.

Yes

Immunisation Status

Have you ever been immunised against the following? Please give year.

Tetanus

Yes

Year

Polio

Yes

Year

BCG (Tuberculosis)

Yes

Year

Diptheria

Yes

Year

Hepatitis B

1st Injection

Yes

Year

2nd Injection

Yes

Year

3rd Injection

Yes

Year

Has your blood test confirmed immunity to Hepatitis B?

Yes

Year

Sickness Absence
Please list how many days you have been absent from work, school, college etc in the last three years due to sickness. For each absence please also indicate the dates and the reason.
Number of days absence	Dates of absence (dd/mm/yy)	Reason (please state if related to a disability)

Declaration

The information I have provided is accurate and I have not withheld any details. I understand that the giving of false information or withholding information could subsequently result in my dismissal.

I will notify you immediately if any of my answers change on my completed form.

I do/do not give permission to my General Practitioner to disclose relevant information to the Occupational Health Department in accordance with the Access to Medical Records Act 1988.

I do/do not wish to see my General Practitioner’s comments before the form is returned to the Occupational Health Department.

I do/do not want to know if I am at risk of early ill-health retirement.

I consent to this data being held by an Occupational Health Unit of a police force on a computer or manual filing system, in accordance with the confidentiality requirements of the Data Protection Act 1998.

Signature of applicant

Date

General Practitioner’s Comments

Please note that a medical examination is not required.

Are you in possession of this patient’s complete medical history?

Yes

From the medical records available, is there any medical reason why your patient should not undertake strenuous physical exercise?

Yes

According to these records and your knowledge of the applicant, do the answers given by him/her in the questionnaire appear correct?

Yes

Are you aware of any other medical information which might be relevant to this application?

Yes

If so, please give details.


General Practitioner’s signature	Date	Practice Stamp

Please note: any fee required for the completion of this form will be paid by the applicant. A medical examination is not required.

CYMED1 October 2004