|
No.
|
Question
|
Answer
|
|
1
|
Do you suffer from diabetes and/or need insulin?
|
|
|
2
|
Do you suffer from epilepsy or fits?
|
|
|
3
|
Do you have any medical conditions, illnesses or disability?
|
|
|
4
|
Are you taking medication causing dizziness, drowsiness or side effects?
|
|
|
5
|
Hospitalisation, illness or operation in last 3 years?
|
|
|
6
|
Alcohol-related illness during last 12 months?
|
|
|
7
|
Used drugs in the past 12 months?
|
|
|
8
|
Mental illness, depression or stress related issues?
|
|
|
9
|
Signed off work due to stress, depression or mental illness?
|
|
|
10
|
Do you have allergic conditions?
|
|
|
11
|
Any physical/medical condition affecting safety?
|
|
|
12
|
Exposure to lead, asbestos, chemical or biological agents in last 6 months?
|
|
|
13
|
Illness due to exposure to lead, asbestos, chemical or biological agents?
|
|
|
14
|
Are you colour blind?
|
|
|
15
|
Difficulty with eyesight?
|
|
|
16
|
Eye injury or eye problems?
|
|
|
17
|
Recurring chest, bronchial or respiratory problems?
|
|
|
18
|
Are you asthmatic?
|
|
|
19
|
Any other respiratory condition?
|
|
|
20
|
Respiratory illness or breathing difficulties in last 12 months?
|
|
|
21
|
Do you suffer from deafness?
|
|
|
22
|
Difficulty hearing normal conversations?
|
|
|
23
|
Do you use vibrating power tools regularly?
|
|
|
24
|
Swelling at base of fingers due to power tools?
|
|
|
25
|
HAVS or vibration-related condition?
|
|
|
26
|
Poor circulation, chilblains or cold extremities?
|
|
|
27
|
Back or musculoskeletal disorders?
|
|
|
28
|
Skin conditions such as eczema or psoriasis?
|
|
|
29
|
Dry, cracked, sensitive or peeling skin?
|
|
|
30
|
Used barrier/moisturising creams at work?
|
|
|
31
|
Medical conditions preventing night shifts?
|
|
