Pre-employment "Medical" Questionnaire For SNAs

Introduction: The purpose of the pre-employment medical questionnaire is to enable Medmark:

  1. determine the fitness of applicants to safely carry out duties of the intended position whilst ensuring compliance with Employment Equality legislation.
  2. screen for underlying medical disorders so that the employers can meet their responsibilities under Health and Safety & Disability Legislation
  3. form the basis of an occupational health record to be held by Medmark. This record may be referred to if the applicant is referred to Medmark at a future date.
Data Protection
The information on this document may be stored in either paper or electronic form. It is for the use of the occupational health service for SNAs. The data will be held in accordance with Data Protection Legislation. The medical information stored will be treated as strictly confidential at all times by Medmark and will not be disclosed to any third parties on an identifiable basis. Statistical information may be compiled on an anonymous basis in group format.

When completing the questionnaire please follow the instructions below.

Complete all sections and answer all questions.

You must provide both your Personal Public Service Number (PPSN) and your school roll number in order for Medmark to consider your application and forward a result to your prospective employer.

If you answer ‘YES’ to any of the questions under the heading ‘HAVE YOU EVER HAD OR DO YOU NOW SUFFER FROM’, then provide the following information on the PEMQ
  • the name the illness
  • state when symptoms first started and when the illness was diagnosed
  • if you attended a specialist /health care professional, give details of who you attended and if investigations/tests were carried out, give details of the results of these investigations/tests. Please state when you last visited a specialist /health care professional and if you have any further appointments
  • if treatment was prescribed, please give details
  • Please indicate if you have completed your treatment and if not indicate when your treatment finishes
  • If you have missed any time from work/college as a consequence if this illness, please give details of when this was and details of the duration of time missed
  • If you have not made a full recovery from this illness, give details of how the illness continues to affect you
  • If you consider your illness is in any way work related, please give details
You may be contacted by the Occupational Health Physician if you do not complete the questionnaire in sufficient detail, and if more information is required. This may delay your application. You may also be requested to attend Medmark for a pre-employment assessment in person.

Thank you for giving this questionnaire your time and attention.

Surname

First Name

PPSN

School Roll Number

Date of birth

Home Address

Name and Address of School

 Contact phone numbers
(landline & mobile) & e-mail address

Landline:

Mobile:   

Email:     

Type of School, tick as appropriate

Primary
Secondary
VEC
Community/Comprehensive

Select Your Security quesion
(*remember this as reference for further enquiry)

Your Answer for Security Question
(*remember this as reference for further enquiry)

 

PLEASE COMPLETE THE FOLLOWING HEALTH QUESTIONNAIRE:  WHERE A “YES” IS PROVIDED IN ANSWER TO ANY OF THE FOLLOWING QUESTIONS PLEASE PROVIDE SOME DETAILS. 

NOTE: MEDMARK MAY CONTACT YOU FOR CLARIFICATION WHERE MEDICAL INFORMATION IS INCOMPLETE.

 

Yes

No

Details

Have you ever completed a pre-employment medical questionnaire for Medmark? If so, please give details

Have you ever been treated or had counselling for any addiction disorder, alcohol or drug abuse?  If so, please give details.

Do you smoke?
If yes, please quantify your daily intake

Do you drink alcohol?If  yes, what is your weekly consumption of alcohol in units?  1 Pint Beer   =  2 Units          Spirit  =  1 ½ Units Glass Wine   =  1 Unit

Have you ever been denied a job on health grounds?

Have you ever been medically retired from any job, or left any job because of ill health? Please give details.

Have you ever had any illness or health related problem that may have been caused or made worse by your work?

Have you attended any doctor for medical care or treatment in the last five years for any kind of health problem? If so, please give reasons.

Are you currently taking any medication? If yes, please state why and the name of the medication.

Are you currently receiving or waiting for, any medication, treatment or investigation at the moment?  If so, please give details.

Have you ever had any illness, medical problem or disability that may currently affect your ability to work safely as a SNA

Have you had any days off sick in the last 2 years? If yes, please give number of days and reasons to the best of your recollection.

 

PLEASE COMPLETE THE FOLLOWING HEALTH QUESTIONNAIRE:  WHERE A “YES” IS PROVIDED IN ANSWER TO ANY OF THE FOLLOWING QUESTIONS PLEASE PROVIDE SOME DETAILS TO INLUDE RELEVANT DATES, DIAGNOSIS, TREATMENT, ONGOING SYMPTOMS. 

NOTE: MEDMARK MAY CONTACT YOU FOR CLARIFICATION WHERE MEDICAL INFORMATION IS INCOMPLETE.

HAVE YOU EVER HAD OR DO YOU NOW SUFFER FROM

Yes

No

Details

Lung/Chest Problems? e.g. Asthma, TB, Pneumonia, Bronchitis

Heart problems or circulatory disorders? e.g. Heart Murmur, Heart Attack, High Blood Pressure, Anaemia, Circulatory Problems, e.g. varicose veins/ankle swelling.

Stomach, Bowel or liver disease, gallbladder or pancreatic problems.

Prostate problems, bladder or continence problems, kidney disorders? e.g. Kidney stones, infections, kidney failure.

Glandular problems? e.g., diabetes or thyroid problems.

 

Disorders of the nervous system? e.g. fits, blackouts, migraine, recurring headaches, epilepsy, stroke, mini stroke, dementia

Psychiatric or mental health illness or psychological problems including anxiety, depression, schizophrenia, nervous breakdown, eating disorders (anorexia/bulimia), panic attacks, burnout

Fatigue syndrome? e .g. post viral fatigue, M.E.

Do you have any eye disorder not corrected with glasses or any other eye problems e.g. colour blindness, lazy eye, glaucoma, cataracts etc.,

Ears, nose, throat or any voice disorders? e.g. deafness, tinnitus, voice weakness/voice projection difficulties, recurring laryngitis

Skin problems? e.g eczema, dermatitis, psoriasis.

Tumours – benign or malignant?

Allergies? e.g. to drugs, food, chemicals.

Back, neck, joint problem or arthritis, gout or any other rheumatic disorder?  e.g. backache, disc prolapse, disc/back surgery, soft tissue injury, occupational back injury, arthritis, rheumatism, fibromyalgia

Work related upper limb disorder (WRULD) or repetitive strain injury (RSI), tendonitis?

Any gynaecological problems?

Any other accidents, illness or injuries?

OCCUPATIONAL HISTORY

Please provide some detail concerning recent positions you have held

Workplace

From Date

To Date

Job Description

 

 

 

 

 

 


DECLARATION

I understand that the purpose of this Pre -Employment Medical Questionnaire is to establish the following:

  • That I am fit for the post for which I am making application
  • That I can carry out the duties of the post without any undue risk to the health and safety of myself or any other person
  • That my employer will have reasonable expectation that I will provide regular attendance at school

I declare that the information I have given is true and complete to the best of my knowledge and that I have not withheld any material facts. I understand that I am responsible for the accuracy of my statement and that if I wilfully suppress and information I risk the loss of appointment.I understand that by submitting this pre employment questionnaire I consent to Medmark Occupational Health furnishing notification concerning my fitness to the named school.

I agree with the above declaration.