PRELIMINARY DATA SHEET FOR PRE-EMPLOYMENT HEALTH EXAMINATION
PERSONAL DATA
Last name
First names
Identity code
Occupation/task
Address
Telephone
Company name
Department
Military service in
Fitness class
Previous employment
Does your work involve exposure
to...
Supervisor
First-aid training completed in
Duration of employment
Noise?
Occupation/task
Dust?
Solvents?
Other?
What?
Describe your current task in a few words:
What do you expect from the new work?
What makes you enjoy your work and feel you are performing a meaningful task?
Which things run smoothly at work?
Describe a possible situation that hinders succeeding in work:
MEDICAL HISTORY OF YOUR IMMEDIATE FAMILY
Has a parent or sibling been diagnosed with the following diseases?
No
Yes
No
Diabetes mellitus
Cancer
Cardiovascular disease
Mental illness
Hypertension
Asthma or hypersensitivity
Yes
Clarification:
HEALTH AND LIFESTYLE
How many days have you been absent from work within the last year?
Do you have or have you previously had any the following symptoms or conditions:
No
Yes
No
Yes
Alcohol abuse
Anaemia or iron deficiency
Other intestinal disease
Asthma
Other stomach symptoms
Epilepsy or other disease of the
nervous system
Rheumatoid arthritis
Disease of the prostate
Joint disorders
Gynaecological diseases
Prolonged dizziness
Paralysis
Chest pain during exertion
Respiratory diseases
Back or neck problems
Eczema or a skin disease
A need for glasses
Thyroid disease
Eye disease or colour-blindness
Jaundice or liver disease
Diabetes mellitus
Elevated blood pressure
Varicose veins
An ear disease or hearing loss
Cardiovascular disease
PRELIMINARY DATA SHEET FOR EMPLOYMENT HEALTH EXAMINATION PAGE 1
No
Yes
No
Gastric ulcer
Cancer or a malignant tumour
Mental illness
Recurring headaches
Migraines
Tuberculosis
Kidney disease
A disorder of the musculoskeletal
system
A sleep disorder
Urinary tract infection
Bloody stools
Hypersensitivity or allergy
Other chronic or long-term disease
What?
Yes
Do you use regular medication or receive continuous treatment?
No
If ‘Yes’, what?:
Yes
?
Surgeries
Occupational illness, work-related diseases, or associated symptoms
Accidents at work or in leisure time
Over the last month, have you often been worried about feelings of melancholy, depression, or despair?
No
Yes
Over the last month, have you often worried about apathy or lack of interest?
No
Yes
How would you characterise your health?
1. Poor
2. Fairly poor
3. Fair
4. Good
5. Excellent
When was the last time you were vaccinated?
Tetanus D
Other – please specify:
Polio
Do you smoke cigarettes or a pipe or use snuff or chewing tobacco? If you answered ‘Yes’, please specify what you use.
No
Yes
Please specify:
Approximately how much daily?
Does the use of alcohol cause you health, social, or other problems?
No
Yes
How many portions of alcohol do you consume weekly? (1 portion = 1 bottle of medium-strength beer, 12 cl of wine or 1 bar portion of
strong alcohol)
Do you use narcotic drugs?
No
Yes
If ‘Yes’, what?
How often during the week do you exercise (either for the purpose of exercising or in the course of daily activities), for 15 minutes at a
time, to such an extent that you sweat and get out of breath?
Do you sleep well?
No
Yes
Do you feel that the various aspects of your life (work, family, friends, hobbies, and so on) are well balanced?
No
Yes
Which things in your personal life do you find relaxing, refreshing, and enjoyable?
Are there any other issues related to your work or health that you would like to discuss? Please specify.
What are your expectations with respect to the operations of Occupational Health Care in relation to your health and well-being?
I hereby confirm that the information I have provided is truthful.
Date
/
.
Signature
PRELIMINARY DATA SHEET FOR EMPLOYMENT HEALTH EXAMINATION PAGE 2