Employee Health & Medical History Form

All information provided on this form is strictly confidential & will become part of your employee record.

PERSONAL INFORMATION

First Name

Surname

Address

Postcode

Date of Birth

Gender *

MaleFemale

Doctor (GP)

Doctor’s Contact Ph No.

PERSONAL HEALTH HISTORY

Immunisations & Dates

Tetanus

YESNO

Year of immunisation

Influenza

YESNO

Year of immunisation

Other

Year of immunisation

Other

Year of immunisation

If you have ticked any of the above, please provide as much detail as possible below

Please list any prescribed medications, as well as over-the-counter drugs (eg vitamins, inhalers, etc)

Name of Medication/Drug

Strength

Frequency Taken

Alcohol

Do you drink alcohol? *

YESNO

Average no. of glasses per day *

Illicit Drugs

Do you currently use illicit/recreational drugs? *

YESNO

Have you ever given yourself illicit drugs with a needle?

YESNO

Smoking

Do you smoke, or have you ever smoked, cigarettes? *

YESNO

If you still smoke, average no. of cigarettes per day *

WorkCover

Have you ever filed a WorkCover claim? *

YESNO

What company were you working for at the time *

Type of injury reported *

Pre-existing Injury or Disease

This statement is to be used to disclose to the employer of any pre-existing injury or disease that you have suffered of which you are aware, and which you could reasonably foresee could be affected by the nature of the proposed employment as per the position description.

Failure to make a disclosure, or the making of a false or misleading disclosure, may disentitle you to compensation pursuant to the Accident Compensation Act, should you suffer any recurrence, aggravation, acceleration, exacerbation or deterioration of your pre-existing injury or disease arising out of, or in the course of, or due to, the nature of your employment.

Do you have any pre-existing injury / disease *

YesNo

Detail of any pre-existing Injury / disease *

Potential Relationship to / impact on employment:

DECLARATION

I, *please type name

, have read and understood all questions asked in this Health and Medical History Form, and have answered these questions honestly.

Signed *

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Date *