Annual Med Q

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Department

Name(Required)

First Middle Last

Date of Birth(Required)

Home Tel

Work Tel

Mobile Tel

Home Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

GP Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Changes to your Health

I confirm that I have reviewed my health questionnaire and there has been no changes to my health in the past year(Required)

Yes

I confirm that I have reviewed my health questionnaire and I have listed the changes below(Required)

Yes

Details of Health Changes

Have you come into contact with any BBV’s (Blood Bourne Virus) since you were initially screened by Occupational Health including Needle Stick Injuries?(Required)

Yes

Have you suffered from methicillin resistant staphylococcus aureus (MRSA)??(Required)

Yes

Have you suffered from clostridium difficile (C-Diff)?(Required)

Yes

Additional Information(Required)

Additional Information (If you have answered yes to any questions above please provide additional information below. Failure to do so will result in the forming being returned/rejected.)

Tuberculosis

Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006) *

Have you lived continuously in the UK for the last year (Include Holidays/ Vacations)(Required)

Yes

If you have answered 'NO' to the above, please list all the countries that you have lived in/visited over the last year, including holidays and vacations. This MUST include duration of stay and dates or this form will be rejected.(Required)

Have you had a BCG vaccination in relation to Tuberculosis?(Required)

Yes

Date of BCG Vaccination(Required)

Do you have a cough which has lasted for more than 3 weeks?(Required)

Yes

Do you have any unexplained weight loss?(Required)

Yes

Do you have any unexplained fever?(Required)

Yes

Have you had tuberculosis (TB) or been in recent contact with open TB?(Required)

Yes

Additional Information (If you have answered yes to any questions above please provide additional information below)(Required)

UK General Data Protection Regulation (UK GDPR)

All information supplied by you will be held in confidence by Healthier Business UK Ltd. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician; however it will not be shown, nor their contents shared with anyone - including Managers, Human Resources Advisors, GP’s, Specialists or third party’s - without your explicit consent. You have the right of erasure (the right to be forgotten), refusal of consent and withdrawal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation. Further information regarding your rights under GDPR can be found on the following: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/ If you wish to have sight of our privacy policy, please send your request to support@hbcompliance.co.uk

Consent

Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing. Further information regarding consent is available on the 'candidate screening leaflet'

Do you consent to this questionnaire, and any supporting documentation, being assessed by an Occupational Health Advisor for the purpose of providing a Fitness to Work Certificate?(Required)

Yes

Do you consent to our Occupational Health Advisor speaking with you regarding any declaration you may have made relating to your medical history?(Required)

Yes

Do you consent to our occupational Health Advisor making recommendations to your employer/agency to assist with your ability to carry out your perspective role?(Required)

Yes

Declaration

I will inform my employer if I am planning to or leave the UK for longer than a three month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Name(Required)

First Last

Date(Required)

Annual Review Medical Questionnaire

Changes to your Health

Tuberculosis

UK General Data Protection Regulation (UK GDPR)

Consent

Declaration