Night Worker Questionnaire - LMR Health & First Aid Limited

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LMR Health & First Aid Limited

07963 773 866
enquiries@lmroccupationalhealth.co.uk

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Night Worker Questionnaire

The Working Time Regulations 1998 require the Company to provide Night Workers with the opportunity of a free health assessment. This questionnaire has been designed to provide this facility.

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Name *

Company *

Date of Birth *

Role *

Phone Number *

Date *

Email *

If you do not wish to complete this form then please answer no to the question below, complete the above section only and then go to the bottom and sign the decline declaration.

Would you like to complete the form in it's entirety? *

Yes
No

Are you taking any daily medication?

Yes
No

IF YES please provide name of medication, dose taken and why you are taking it BELOW *

Do you currently suffer from / or within the past 2 years suffered from any of the following?

Dizzy Spells *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding your Dizzy Spells *

High Blood Pressure *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding your High Blood Pressure *

Heart Problems *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding your Heart Problems *

Stomach or Bowel Problems *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding your Stomach or Bowel Problems *

Diabetes *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding your Diabetes *

Chronic Chest Conditions *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding your Chronic Chest Conditions *

Sleep Difficulty / Diagnosed with a Sleep Disorder *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding your Sleep Difficulty or Sleep Disorder *

Depression / Anxiety / Stress *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding your Depression, Anxiety or Stress *

Are You A New or Expectant Mother *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding being a new or expectant Mother *

Do You Have Frequent Minor Illnesses *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding Frequent Minor Illnesses *

Do You Believe Working Night Shifts Has Impacted Your Health In Any Way? *

Now / Within Last 2 Years
Longer Than 2 Years Ago
Never

Please provide further details regarding how working Night Shifts has impacted your health *

Consent / Declaration

Declaration *

I declare that, to the best of my knowledge the information I have given in this document (Night Worker Questionnaire) is correct

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Signature *

Date *

Require Phone Call *

I understand that I may be required to have a telephone call with Occupational Health (OH) to obtain further information if required. To discuss your responses if applicable to this document and it is my responsibility to ensure that I am available when required, within 3 – 5 days of submitting this form on the telephone number provided on this document. I will be informed if any further medical information may be required during the telephone assessment.

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Signature *

Date *

Please provide your consent for a certificate to be sent to your employer

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Signature *

Date *

Do not wish to complete the form *

“I do not wish to complete the questionnaire on this occasion.” (Please sign and date below)

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Signature *

Date *

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