Appendix 1 – Medical transcript (to be filled by your general practitioner)

BASIC HEALTH QUESTIONNAIRE

for job applicants

……………………………………………

This questionnaire will be completed by the general practitioner/attending physician

Name/names and surname ……………………………………….....................................male/female

Address of permanent residence

………………………………………………………………………......................................

Phone/mobile………………….........................E-mail………………………………………………………….............

Last vaccination against tetanus………………………............................

General practitioner contact details.........................................................................................................

What is the job applicant currently being treated for or has he/she suffered from any of the following diseases
and disorders in the past?

(If yes, mark as and include when-the year or since when has he/she had the given condition or disease)

High blood pressure.................................................................

Heart disease, myocardial infarction .................................................................
Stroke .................................................................
Family history of death before the age of 60 years, including the deceased´s relationship with the applicant and the cause of
death..................................................
Diabetes .................................................................
Mental illness, attempted suicides .................................................................
Infectious hepatitis (jaundice) or other liver disease...................................................
HIV positivity/AIDS?...................................................
Mental illness or neurological disease?...................................................
Respiratory tract disease, asthma?...................................................
TBC?...................................................
Bone or joint disease (e.g. epicondylitis, tendovaginitis) ?...................................................
Spinal disease?...................................................
Peripheral nerve disease (nerve compression syndrome) ?...................................................
Vision and hearing disorders?...................................................
Uses hearing aid, wears dioptric glasses or lenses (strength?) ...........................................
Sleep disorders?...................................................
Unconsciousness/coma, seizures (e.g. epilepsy, migraine) ...............................................................
Other serious disseases........................................................ Which?........................................................................
Injuries (type, date): ...............................................................
Consequences: ...............................................................
Surgery (type and date, consequences): .............................................................
Allergy (type, medication): .....................................................................
Smoker, how many per day, for how long ? ............................................
Former smoker (how long):……………………………………….
Drinks alcohol regularly/irregularly? Amount and type of alcohol ..................
Regular/occasional drug user (type, amount): ........................
 Appendix 1 – Medical transcript (to be filled by your general practitioner)

Has been treated for addiction (when)?.................................. Duration of abstinence.............................................................

Regular medication…………………………………………………………………………………………………………………

In women:

Gynecological complaints:
Date of last preventive gynecological exam?
Hormonal contraception (which)...............................................................  

Place .......................................... date:................................................ Doctor´s signature, specialization, stamp

 Appendix 2 – Medical transcript (to be filled by your general practitioner)

ZÁKLADNÍ ZDRAVOTNÍ INFORMACE

o uchazeči o zaměstnání u firmy

……………………………………………
dotazník vyplní praktický lékař

Jméno/jména a příjmení ……………………………………….....................................muž/žena

Adresa trvalého pobytu …………………………………………………………………………......................................

Tel. číslo/mobil………………….........................E-mail………………………………………………………….............

Poslední očkování proti tetanu………………………............................

Kontakt na registrujícího praktického lékaře.........................................................................................................

S čím se léčí uchazeč o zaměstnání, nebo prodělal v minulosti tato onemocnění?

(pokud ano, označte a uveďte kdy – rok, příp. odkdy)

Vysoký krevní tlak .................................................................

Onemocnění srdce, infarkt .................................................................
Mozková mrtvice .................................................................
Úmrtí před 60. rokem věku v rodině, u koho a důvod?...................................................
Cukrovka .................................................................
Duševní nemoci, sebevražedné pokusy .................................................................
Infekční žloutenka nebo jiné onemocnění jater...................................................
HIV pozitivita/AIDS?...................................................
Duševní nemoc či nervové onemocnění?...................................................
Onemocnění dýchacího traktu, astma?...................................................
TBC?...................................................
Onemocnění kostí, kloubů (např. epikondylitidy, tendovaginitidy) ?...................................................
Onemocnění páteře?...................................................
Onemocnění periferních nervů (úžinové syndromy) ?...................................................
Poruchy zraku či sluchu?...................................................
Užívá naslouchadla, dioptrické brýle či čočky (jaké síly?) ...........................................
Poruchy spánku?...................................................
Bezvědomí či záchvatovitá onemocnění (např. epilepsie, migrény) ...............................................................
Jiná závažná onemocnění........................................................ Jaká?........................................................................
Úrazy (jaký a kdy): ...............................................................
Následky: ...............................................................
Operace (jaké a kdy, následky): .............................................................
Alergie (druh, medikace): .....................................................................
Kuřák, kolik denně, kolik let? ............................................
Exkuřák (jak dlouho):……………………………………….
Pije alkohol pravidelně/nepravidelně? Množství a druh alkoholu ..................
 Appendix 2 – Medical transcript (to be filled by your general practitioner)

Užívá drogy pravidelně/nepravidelně?.(druh, množství): ........................

Léčil/a se pro závislost (kdy)?.................................. Jak dlouho abstinuje?..............................................................
Pravidelná medikace…………………………………………………………………………………………………………………

U ženy:

Gynekologické potíže:
Datum poslední preventivní gynekologické prohlídky?
Hormonální antikoncepce (jaká)...............................................................  

V .......................................... dne:................................................ Podpis lékaře, specializace, razítko