Do you have any allergies or underlying health conditions we need to be made aware of? *
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No
Yes
Prefer not to say
Please tell us about these allergies and/or underlying health conditions *
Is there anything in your past or present medical history that may make it difficult for you to fulfil your role (Please include any illness/impairment/disability (physical or psychological))
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No
Yes
Prefer not to say
Please provide further details *
Are you having or waiting for treatment (including medication) or investigations at present?
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No
Yes
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Do you have any communication difficulties? (Please include any speech, hearing, visual and sensory impairments)
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No
Yes
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In the past or present have you required any specialist opinion, surgical intervention or therapy?
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No
Yes
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Have you ever experienced any back, neck, shoulder or wrist problems?
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No
Yes
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Do you have any known allergies?
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No
Yes
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Have you been exposed to significant noise at work or leisure?
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No
Yes
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Have you any past or present history of respiratory issues? (Breathing)
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No
Yes
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Do you have any issues (medical or non-medical) which might impact on your ability to travel or drive?
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No
Yes
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Do you have any past or present history of depression, anxiety or stress or any other mental health condition?
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No
Yes
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Do you have any past or present history of addiction to or misuse of substances such as alcohol, steroids or drugs (illegal or prescribed)?
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No
Yes
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Do you consider yourself to have any disabilities?
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No
Yes
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Are you exempt from wearing a facemask?
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No
Yes
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Is there anything else that we should know?
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No
Yes
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Please provide further details *