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  • 1. Woodstock School Medical Questionnaire Medical Questionnaires are necessary to determine that: • There is no risk of aggravating a pre existing medical condition given the unique location of Woodstock School and it’s environment • The applicant is able to productively carry out the duties of the position safely • The applicant should not, because of a medical condition, increase risk to other staff or students • The applicant should be aware that given our location we have limited access and resources to mental health or counselling support Confidentiality - The medical questionnaire and the information contained within will be treated as a confidential document. Name:____________________________________________________________________ Age:_________ Date of Birth:_____________________ Sex: M/ F Blood Group: _____ Please provide name and address of your current Family Doctor or Medical Specialist below: Name: _____________________________________________________________________ Address:____________________________________________________________________ __________________________________________________________________________ Phone No. _______________________ Email:____________________________________ Present Health Status YES NO Please give details where appropriate Are you currently attending a doctor, counsellor or mental health specialist? Are you at present on any medication or treatment prescribed by a doctor? Are you a smoker? If yes please give details. Do you drink alcohol? If so how N.B one unit = ½ pint beer or 1 med many units per week? glass of wine. What is your height? ……ft……ins or ……..m /home/pptfactory/temp/20101021144718/medical-form1818.doc
  • 2. What is your weight? ……st……lbs or ……..kgs Do you have or have you had any of the following conditions? If yes # for any question you will need to provide further information in the YES NO ‘comments box’ and/or over the page. 1 Heart disease or high blood pressure? 2 Blood disorder (e.g. anaemia, leukaemia)? 3 Kidney or bladder problems? 4 Shortness of breath or chest pain on exertion? 5 Lung disease (e.g. asthma, bronchitis, T.B.)? 6 Epilepsy or fits? 7 Dizziness, faints or turns? 8 Frequent headaches or migraines? 9 Liver disease (e.g. cirrhosis, hepatitis)? 1 Visual or hearing problems? 0 1 Mental health issues (anxiety, depression, stress)? 1 1 Allergies? 2 1 Skin disease (eczema, dermatitis)? 3 1 Any significant infectious disease (e.g. hepatitis, rheumatic fever)? 4 1 Back or joint pain (arthritis, rheumatism)? 5 1 Diabetes, thyroid or other gland problem? 6 1 In the last 5 years have you received any medication/treatment? 7 1 In the last 5 years have you had any operation or been hospitalised? 8 1 Any other injury/illness/health condition NOT covered above? 9 Are all immunisations up to date for your current country of residence? YES NO Immunisations Please include dates/other relevant information Hepatitis A YES / NO Hepatitis B YES / NO Rabies YES / NO Typhoid YES / NO Polio YES / NO Tetanus YES / NO /home/pptfactory/temp/20101021144718/medical-form1818.doc
  • 3. All immunisations are available and can be given at the Woodstock School Health Centre. # Duration and dates of condition Current status Declaration 1. I declare that, to the best of my knowledge, the information I have given is correct. /home/pptfactory/temp/20101021144718/medical-form1818.doc
  • 4. 2. I understand that failure to disclose relevant information or giving of false information may affect my employment at Woodstock School. Name of Applicant _____________________________________ (please print) Signature of Applicant __________________________________ Date ________________ /home/pptfactory/temp/20101021144718/medical-form1818.doc
  • 5. /home/pptfactory/temp/20101021144718/medical-form1818.doc