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MEDICALM

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Job Dashboard
Candidates
Clients
- Clients Contact
Compliance
Contact Us

New Starter Clinical Form

Confidential

Due to the nature of the role you have applied for we need to carry out a complete a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status.

Before health clearance is given for employment you may be contacted by Healthier Business UK Ltd and may need to be seen by an occupational health advisor or physician with gained consent. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice.

Title *

First Name *

Surname *

Date of Birth *

Home Telephone Number *

Mobile Number *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Country *

GP Street Address *

GP Apartment, suite, etc *

GP's City *

GP's State/Province *

GP's ZIP / Postal Code *

GP's Country *

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?YesNoStaff Groups only

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?YesNoStaff Groups only

Are you having, or waiting for treatment (including medication) or investigations at present?YesNoStaff Groups only

Do you think you may need any adjustments or assistance to help you to do the job?YesNoStaff Groups only

Have you suffered from methicillin resistant staphylococcus aureus(MRSA) *YesNo

Have you suffered from clostridium difficile (C-Diff) *YesNo

Have you ever had chicken pox or shingles? *YesNo

Have you ever had BBV (Blood Brone Virus)? *YesNo

Have you lived outside the UK or had an extended holiday outside the UK in the last year? *YesNo

Have you had a BCG vaccination in relation to Tuberculosis? *YesNo

Have you ever had a cough which has lasted for more than 3 weeks? *YesNo

Have you ever had unexplained weight loss? *YesNo

Have you ever had unexplained fever? *YesNo

Have you ever had tuberculosis (TB) or been in recent contact with open TB? *YesNo

Have you ever had triple vaccination as a child (Diptheria / Tetanus / Whooping cough)? *YesNo

Have you ever had Polio immunisation? *YesNo

Have you ever had Tetanus immunisation? *YesNo

Have you ever had Hepatitis B immunisation? (if Yes is ticked please give dates below) *YesNo

Date From

Date To

Proof of immunity from Varicella *

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You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity

Proof of immunity from Tuberculosis *

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We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)

Proof of immunity from Rubella, Measles & Mumps *

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Certificate of "two" MMR vaccinations or proof of a positive antibody for Rubella and Measles

Proof of immunity from Hepatitis B *

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You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above

Proof of immunity from Hepatitis B Surface Antigen (EPP Candidates Only)

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You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above

Proof of immunity from Hepatitis C (EPP Candidates Only)

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Evidence of a Hepatitis C antibody Test (Inc. Hepatitis C RNA/PCR if applicable). Reports must be an identified validated sample. (IVS)

Proof of immunity from HIV (EPP Candidates Only)

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Evidence of a HIV I and ll antibody test (Inc. DNA viral loads if applicable). Reports must be an identified validated sample. (IVS)

Will you role involve Exposure Prone Procedures? *YesNo

The General Data Protection Regulation (GDPR) (EU) 2016/679

All information supplied by you will be held in confidence by Healthier Business UK Ltd.Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician, however it will not be shown, nor thier contents shared with anyone - including Managers, Human Resources Advisors, GP, Specialist's or third party's - without your explicit consent.You have the right of erasure (the right to be forgotten), withdrawal of consent and refusal of consent without detriment. The only exceptions to this may be a court order for release of records in a judicial dispute, or where there is a public responsibility obligation.

I understand that following this assessment, recommendations may be provided to assist my health at work; *I give consent for the Healthier Business UK Ltd to make recommendations and for my employer/agency to provide these recommendations to my placementI would like to see a written copy of any recommendations Healthier Business UK Ltd may make before my employer/agency provide them to my placement

Declaration *I will inform my employer if I am planining to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Name *

Date *

Upload a Signature *

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