Woodgrange Medical Practice

LUM: Management arrangements to Assure Medical Fitness

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then please complete a handwritten form when you visit the Practice.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Please complete this form to the best of your knowledge. If subsequent events prove you have completed this form untruthfully, this may lead to your dismissal. Have you ever had any of the following?

• Pre-placement, PTS, Contractors, Track Certification

• LU and TfL Staff Periodic Medicals

Complete sections A, B (if relevant) and section E, sign the form and declaration

- If the answer to any of the following questions is 'Yes,' please give details -

RECENT MEDICAL HISTORY

1. Have you been medically examined within the last two years?

Yes 

No 

Please provide details, including dates:

2. Have you had to seek advice from a GP or Specialist in the last two years?

Yes 

No 

Please provide details, including dates

3. Are you receiving any medicine, pills / tablets from a doctor, or taking any over-the-counter medication?

Yes 

No 

Please provide details, including dates:

4. Have you had time off from work due to illness in the last two years?

Yes 

No 

If you answered 'yes,' please estimate how many days or weeks

On how many occasions?

5. Are you having or waiting to have any treatment, investigations or operations of any kind at the moment?

Yes 

No 

Please provide details, including dates:

DO YOU SUFFER FROM, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? IF SO, PLEASE PROVIDE DETAILS:

6. Epilepsy, fainting attacks or attacks of giddiness?

Yes 

No 

Please provide details:

7. Severe, frequent or prolonged headaches or migraine?

Yes 

No 

Please provide details:

8. Have you ever suffered from anxiety / depression / stress / panic attacks / any mental illness, which required treatment from your GP?

Yes 

No 

Please provide details:

9. Have you ever had any mental illness including psychological & psychiatric illness that required specialist treatment?

Yes 

No 

Please provide details:

10. Do you have personality disorder?

Yes 

No 

Please provide details:

11. Do you have dyslexia?

Yes 

No 

Please provide details:

12. Asthma, bronchitis, hay fever or any other chest condition including persistent cough?

Yes 

No 

Please provide details:

13. Have you ever been treated for any eating disorders (i.e. Bulimia / anorexia)?

Yes 

No 

Please provide details:

14. Have you ever had, or do you have a drink or drug problem?

Yes 

No 

Please provide details:

15. Have you ever consulted a doctor about a drink or drug related problem? i.e. Have you received professional help for this in the past 10 years?

Yes 

No 

Please provide details:

16. Diabetes?

Yes 

No 

Please provide details:

17. Diseases of the heart or blood vessels?

Yes 

No 

Please provide details:

18. Raised blood pressure?

Yes 

No 

Please provide details:

19. Skin problems or diseases such as dermatitis, eczema, psoriasis or sensitive skin? If so, please indicate specific area:

Yes 

No 

Please provide details:

20. Do you have any allergies? If so, please list them:

Yes 

No 

Please provide details:

21. Have you ever had any back problems, including injury or backache?

Yes 

No 

Please provide details:

22. Did your back problems currently require investigation or treatment?

Yes 

No 

Please provide details:

23. Do you have any difficulties with standing, bending, lifting or any other movements?

Yes 

No 

Please provide details:

24. Difficulty moving rapidly over short distances (10m)?

Yes 

No 

Please provide details:

DO YOU SUFFER FROM, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? IF SO, PLEASE PROVIDE DETAILS:

25. Problems with your hands, arms, legs or feet which affect movement or normal use?

Yes 

No 

Please provide details:

26. Disorders of the bladder or kidney?

Yes 

No 

Please provide details:

27. Blood disorders, jaundice or hepatitis?

Yes 

No 

Please provide details:

28. Any types of cancer?

Yes 

No 

Please provide details:

29. Eye disease or visual problem?

Yes 

No 

Please provide details:

30. Do you have any difficulty distinguishing all of the various colours?

Yes 

No 

Please provide details:

31. Do you have problems with using Visual Display Equipment?

Yes 

No 

Please provide details:

32. Are you hard of hearing or have any hearing difficulties?

Yes 

No 

Please provide details:

33. Do you wear a hearing aid?

Yes 

No 

Please provide details:

34. Do you have any problems hearing conversation in normal circumstances?

Yes 

No 

Please provide details:

35. Have you ever left employment on grounds of ill health or unsatisfactory attendance?

Yes 

No 

Please provide details:

36. Disability or industrial injury benefit claim?

Yes 

No 

Please provide details:

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

Yes 

No 

Please provide details:

38. Do you suffer from excessive daytime sleepiness?

Yes 

No 

Please provide details:

39. Does your job require working nights? If yes, please tick appropriately IF permanent nights or shifts:

Yes 

No 

Please provide details:

Permanent nights 

Shifts 

40. Any other illness, injury or operation not already mentioned above?

41. Have you any other concerns about your health?

42. Do you smoke?

Yes 

No 

If yes, how many per day (cigarettes / cigars / tobacco):

43. Have you ever attended any London Transport or London Underground Occupational Health Department before?

Yes 

No 

If yes, which year?

DECLARATION I declare that all the answers given above are, to the best of my belief, true and complete. I understand that any significant omission or misrepresentation could be disclosed to my employing and/or recruitment manager at their request. I understand that if needed or if the questionnaire is incomplete then I may be asked to attend an interview at the Occupational Health Department. For PTS purposes only: I understand that if applicable, my details will be made available to NCCA (National Competency Control Agency) Signed: Date:

EMPLOYEE CONSENT FORM Occupational Health Assessment and Report

I CONFIRM THAT:

I agree to an Occupational Health (OH) report being provided to my manager / PMA / HR and 

I consent to further advice and / or OH reports being provided to my manager / PMA / HR at a later date concerning matters relevant to this referral 

The General Medical Council requires an Occupational Health Practitioner to offer to show or provide you with a copy of the report before it is sent to your manager / PMA / HR

DO YOU WISH TO SEE A COPY OF THE REPORT BEFORE IT IS SENT?

NO - I do not wish to see the report 

NO - I am happy to receive the report at the same time as my manager / PMA / HR 

YES - I would like to see/receive the report before it is sent to my manager / PMA / HR 

Please indicate how you would like to receive your copy of the report by selecting one of the options below (complete as appropriate):

By email address:

By postal address:

You may be offered a copy of the report (if available) at the time of the appointment. If so please indicate below: