Exam (elaborations) Physical Activity 310987

The health assessment is required to ensure that the presence of any medical condition, injury or disability does not result in an increased risk of illness or injury to yourself or others arising from the requirements of the job for which you have applied. The assessment will be limited to conditions, which may be relevant to your current capacity to perform the essential requirements of the job and will remain confidential to the business. Please complete the questionnaire below. Depending upon the job for which you have applied, a limited clinical assessment and performance of tests may also be required. Do you have, or have you ever suffered from any of the following? (Tick appropriate box). 1. Clinical Assessment A 2. Clinical Assessment A B 3. Clinical Assessment C Pain, discomfit or loss of function affecting the: A. Neck B. Shoulder C. Arms or wrists Pain, discomfort or loss of function affecting the: A. Back B. Knees C. Ankles or feet Deafness Difficulty hearing Ringing in ears 4. Clinical Assessment D E F 5. Clinical Assessment G 6. Clinical Assessment H Impairment of vision Colour deficiency Use of contact lenses Dermatitis/Eczema Psoriasis Other skin problems Asthma Bronchitis Shortness of breath Wheezing Pneumothoraces Other chest problems Smoking Hay fever/allergies 7. Clinical Assessment I J 8. 9. Heart attack Angina Heart murmur Palpitations Blackouts/fainting Vertigo/loss of balance Excessive daytime sleepiness Chest pain High blood pressure Fear of confined spaces Thyroid problems 10. 11. Clinical Assessment K 12. Liver problems e.g. Hepatitis Jaundice Other liver problems Kidney problems Psychiatric or nervous problems 13. Clinical Assessment J 14. Clinical Assessment J 15. Epilepsy/Fits Co-ordination problems Fear of heights 16. 17. 18. Do you take any medications Any condition which would prevent you from wearing safety footwear or other personal protective equipment Misuse of illegal drugs or alcohol 19. 20. 21. Hernia Diabetes Do you suffer from any allergies