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?

 
 

Please provide details, including dates:

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

 
 

Please provide details, including dates

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

 
 

Please provide details, including dates:

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

 
 

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?

 
 

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?

 
 

Please provide details:

7. Severe, frequent or prolonged headaches or migraine?

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

10. Do you have personality disorder?

 
 

Please provide details:

11. Do you have dyslexia?

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

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?

 
 

Please provide details:

16. Diabetes?

 
 

Please provide details:

17. Diseases of the heart or blood vessels?

 
 

Please provide details:

18. Raised blood pressure?

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

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?

 
 

Please provide details:

26. Disorders of the bladder or kidney?

 
 

Please provide details:

27. Blood disorders, jaundice or hepatitis?

 
 

Please provide details:

28. Any types of cancer?

 
 

Please provide details:

29. Eye disease or visual problem?

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

33. Do you wear a hearing aid?

 
 

Please provide details:

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

 
 

Please provide details:

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

 
 

Please provide details:

36. Disability or industrial injury benefit claim?

 
 

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?

 
 

Please provide details:

38. Do you suffer from excessive daytime sleepiness?

 
 

Please provide details:

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

 
 

Please provide details:

 
 

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

41. Have you any other concerns about your health?

42. Do you smoke?

 
 

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

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

 
 

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:

 

 

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?

 

 

 

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: