Department of Occupational Medicine

Pre-placement Assessment Questionnaire

(Private & Confidential)
Please print your answers and complete all sections
Position Applied For Organisation Applied For Date of Birth Today's Date

Surname Forename Mobile Number Email Address

Telephone (home) Telephone (work) Male/ Female Country of Birth

Address Name and address of family doctor

Proposed starting date: No. of contracted working hours/average week:

Confidentiality
When you have completed and signed the questionnaire, please send it to the Department of Occupational Medicine.
This form will be seen only by the Department of Occupational Medicine who will keep it securely, quite separately
from any other employment records. The information given on the form will be used to determine your fitness to work
in the organisation. A recommendation will be issued to the appropriate authorities accordingly.
Declaration
I hereby certify that I voluntarily undergo this medical assessment and agree to abide by the results. The answers to
these questions are accurate to the best of my knowledge. I acknowledge that failure to disclose information or
submission by me of information, which is subsequently found to be false or misleading, may render my
attachment with the organisation null and void.

Signed _________________________________________ Date: ______________________________

I consent to the Consultant in Occupational Medicine or Occupational Nurse seeking further information from any
doctor or health professional who at any time has attended me concerning anything which affects my physical or
mental health if deemed necessary by the Department of Occupational Medicine

Signed _________________________________________ Date: ______________________________

Immunisation History - Mandatory

Have you ever had the following illnesses or been vaccinatinated against them?
Please attach documentary evidence
Disease Vaccination Illness Dates if known
Measles
Mumps
Rubella
Chicken Pox /Shingles
Hepatitis B
TB (BCG)
Tuberculin Skin test
(Mantoux)
Hepatitis A
Tetanus
Other ( e.g IGRA)
 Medical History

PLEASE COMPLETE THE FOLLOWING HEALTH QUESTIONNAIRE: ANSWER YES OR NO. GIVE FURTHER INFORMATION
ON THE RIGHT IF YOU HAVE ANSWERED YES TO ANY QUESTION. USE ANOTHER BLANK PAGE , IF REQUIRED.
Yes No Details
Do you consider yourself to be in good health ?
Have you ever in your life sufferred from any of
the following:
1 Fainting, black outs giddiness, epilepsy
permanent weakness of hand, limb, recurring
headaches including migraine, stroke
2 Heart problems or circulatory disorders? E.g
heart murmor, heart attack, high blood pressure
anaemia, circulatory problems, e.g varicose
veins/ ankle swelling
3 TB, persistent cough or sputum production,
coughing up of blood, chest pain, excessive
tiredness, unexplained weight loss, fever,
sweating (especially at night)
4 Astma, Bronchitis or pneumonia or any other
breathing difficulty
5 Mental illness, anxiety, depression, nervous
breakdown, overdose or self harm, eating
disorders for example Anorexia Nervosa,
Bulimia, Dyslexia, work stress, or attendance
with a Psychiatrist or Psychologist
6 Skin disease e.g. Psoriasis, Eczema, Dermatitis
or moles
7 Are you allergic to any drugs, chemicals, dust,
food or latex?
8 Have you ever been admitted to hospital because
of an allergic reaction or anaphylaxis?
9 Gastric disorder e.g stomach, bowel, gall bladder
liver disease, jaundice or pancreatic disease
10 Arthritis, joint problems, gout, back or neck
trouble? E.g Backache, injury, disc prolapse
disc/back surgery, whiplash, occupational
back injury?

11 Lost time at work due to back ache

12 Work related upper limb disorder (WRULD) or
repetitive strain injury (RSI), tendonitis?
13 Diabetes, thyroid or other endocrine disorder
14 Eye disorder or disturbance of visiion e.g colour
blindness, glaucoma, lazy eye etc.
15 Have you ever tested positive for Hepatitis B,C
HIV or any other blood bourne virus?
16 Kidney disease e.g kidney stones, infections,
kidney failure or any prostate problems
17 ENT e.g tonsilitis, ear problems including
deafness or infections, hay fever, siniusitis
18 Fatigue syndrome, including post viral fatigue,
ME, burn out etc.
19 Tumour, growth, cancer (benign or malignant)
20 Any infectious disease which has led you to
become a carrier e.g. salmonella, hepatitis or HIV
 Medical History

Yes No Details
21 Gynaecological problems
22 Do you smoke?
If yes, please quantify your daily intake
23 Do you exercise/ take part in sport activities?
How often / times per week?
What type of activity?
What hobbies do you have?
24 Do you have any hobbies that may involve
exposure to chemicals or other hazards
25 Do you drink alcohol?
If yes, what is your weekly consumption
alcohol?
i.e 1 pint beer = 2 units
1/2 pint beer = 1 unit
spirit = 11/2 units
glass wine = 1 unit
26 Has your alcohol intake changed in the last
two years? If so please quantify
27 Are you currently using or have you used in the
last five years any drugs of abuse? E.g cocaine
opiates (i.e heroin/ methadone etc.) ectasy
amphetamines, marijuana etc.
28 Have you ever been treated or had counselling for
alcohol or drug abuse? If so, please give details
29 Have you ever been denied a job on health
grounds?
30 Have you ever had to give up a job for
health reasons or injury?
31 Have you ever been denied life or permenent
health insurance on health grounds?
32 Have you ever applied for or received
compensation for a disease, accident or injury?
33 Are you attending or have attended a doctor or
hospital for medical care or treatment in the last
five years?
34 Are you currently taking medication including
injections/ pills ( prescribed or unprescribed )?
If so, please give name of medication and indicate
the nature of the problem
35 How often have you visited your doctor in the last
year? Please give details
36 Have you ever been absent from work due to
illness/injury for a continuous period in excess of
two weeks
37 Sexually transmitted or tropical diseases?
38 Any other illness, injury, disabililty or medical
condition not mentioned above?
39 Have you ever had a chest X-Ray?
If yes, please specify for what reason and when?
40 Have you ever undergone an operation?
If yes, please give details including year
41 Have you ever consulted a medical or surgical
specialist for any reason?
 Yes No Details
42 Are you currently on a waiting list for any
hospital treatment/ assessment?
43 Is your eyesight normal?
44 Any relevant family history of illness?
45 Have you ever tested positive for MRSA
Height: Weight:
(In metres, without shoes) (In kilograms in indoor clothes)
Do you have any problems or have you had any problems in the past with
Yes No Yes No Yes No
Standing Bending Working at heights

Walking Moving your neck or back Climbing stairs

Lifting Using your hands or elbows

Have you attended a manual handling training course? Date course completed

Occupational History
Please list your jobs. Starting with the last one and working back to school. (Include part times jobs held for
over three months). Please continue on a separate sheet, if necessary
Please state year you left secondary school
Dates from - to Workplace Job description

Have you ever experienced any health effects or injury

that you associated with workplace exposure i.e
needle stick / inoculation injury ?
Did you ever work with a substance that gave you a
rash, made you short of breath, cough or wheeze or
caused strain in your limbs or back?
Have you ever worked for a year or more in a dusty
job?
Have you ever been exposed to gas or chemical fume
at work?
Have you ever worked for a year or more in a noisy
job?

Persons expected to use a computer or visual display unit (VDU) on a regular basis should forward a recent eye
test report from their optician / optometrist.
Applicants should note that any offer of employment / attachment is subject not only to medical fitness, but
also to other requirements laid down by the hospital or university authorities.

For Processing by Department of Occupational Medicine

Assessment: Deemed Fit Deemed Unfit Deemed Fit with restriction Fit for temporary duty, needs review

Comments:

Human Resource Department notified Yes No

Signed: Date:
Consultant in Occupational Medicine / CNM in Occupational Medicine

Revised June 2015

 Exposure Prone Procedures

EPP's are those invasive procedures where there is a risk that injury to the worker may
result in the exposure of the patient's open tissue to the blood of the worker. As of the
7th July 2008 all staff starting a new position in the HSE where they may be required
to perform EPP have to provide evidence that they are immune to and not infectious
for Hepatitis B and not infectious for Hepatitis C.

Medical staff & Nursing Staff (including medical students on clinical placement)
who may be involved in EPP's are clinical staff who work within:
Surgical areas
Theatre
Department of Emergency Medicine
Obstetrics & Gynaecology
Intensive Care Unit
Renal Units

It is necessary to provide an Identified Validated Sample (IVS), the attendee provides

photographic identification - a passport or driving license at the time of serology
The following blood tests are performed
Hepatitis B antibody
Hepatitis B core antibody
Hepatitis B surface antigen
Hepatitis C antibody

If available please submit a copy of completed laboratory results/ EPP clearance

certificate from your Occupational Health Department.
If results are unavailable please contact the Department of Occupational Medicine
and we can facilitate your attendance at the serology clinic upon coomencement
of employment.