CTR PRE-EMPLOYMENT QUESTIONNAIRE (INCLUDING MEDICAL) ‘SECTION A: PERSONAL PARTICULARS (To be completed by New Hire) Date Tel No. Name Foxton PASSPORT /FIN No. Dest Date of 8th PARTA: MEDICAL HISTORY [conomons YES | no | DETAILS (Please furnish, where applicable) [Do you have. or have you ever had, the following conditions? age sERSe aT TET SAREE Te SEE] OF AAT HSE sabi [Colour etna [Heaing Loss [Skin grobiems eg eczema, psoriasis, dry senstive skin. Tergyio any duga or chericas og latex, alchahal, ages, \vaccines, egg proteins, yeast [Heat Disease! High Blood Pressure [Gang disorders eg asta, peuont [Endocmne deorders og dabcles, tyrod UScare or Oe GI (ssorders [History of Cancer [Kidney or bladder dworders Fis, biackouts, farting tacks or gadis [Pojchaine ines, depression o° arwoly [Neadback nies, back or neck ache [Migraine Infectons ep Ubereawe, hepa AB or © [Long Term Meciation Ifthe answer to the following questions is ‘YES" please give detalls, \doctor using a separate sheet it necessary. Tncluding dates, diagnosis, aending Have you eve teceved hospi Weare, a5 an paVETTOTE lpatent? [Ae you tal any meTicalon or ofr eaten Tama Goer or lexacttioner? PARTE : SOCIAL HISTORY & RESPONSIBILITY the answer to the following questions i "YES' please give more DETAILS. includ amount per day or week [conomons ves | no DETAILS (Please furnish, where applicable) [Do you smoke or has been a evoker belo? [bo you dink steohol regulary? [Go yu have ny VISIBLE TATTOO when you aren anomie |shor sleeves, cress, skit (F) I yes, tmust be removed or covered loyiaser inthe course of your work, have you been terminals? in your professional role as nurse, have you sufered Wom any medial consion that may compromise your work? PART : DECLARATION Please read carefully before signing: | certy hat the above information in this medical forms tue and accurate to he best of my knowledge. lunderstaresthat sould Iknownty oF deierataly winks or cst my medical story my offer of employment maybe immediately \hdrawn or may be abl to star ismissal f employed. This form also authenses te cease of any infematon hereby {Thereafter canceming my medical contin by any practioner or hospital the relevant Dushonty NavelSiananre Date Updated as at 2192022