Woodstock School Medical Questionnaire
   Medical Questionnaires are necessary to determine that:

   •   There is no risk...
What is your weight?                                  ……st……lbs or ……..kgs



    Do you have or have you had any of the f...
All immunisations are available and can be given at the Woodstock School Health
Centre.




#   Duration and dates of cond...
2. I understand that failure to disclose relevant information or giving of false information
      may affect my employmen...
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Medical Form:

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Medical Form:

  1. 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. 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. 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. 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. 5. /home/pptfactory/temp/20101021144718/medical-form1818.doc

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