University of CambridgeHealth Assessment Questionnaire for Night Workers Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Mr/Mrs/Miss / Ms / Dr/Prof / Other: First Last Date of Birth:(Required) MM slash DD slash YYYY Age(Required)Job title(Required)Supervisor(Required)Home tel(Required)Work tel(Required)Mobile(Required)Email(Required) Data Protection InformationThe information that you supply on this questionnaire will be held in confidence by the University Occupational Health Service as part of your occupational health record. For full details of how your personal information is used by the University Occupational Health Service, please see http://www.oh.admin.cam.ac.uk/general-information/confidentiality-statement.Please specify your weekly hours of work / shift pattern(Required)Do you suffer from any of these conditions?The following medical conditions could possibly affect your health and ability to safely carry out night work, or could be made worse by night work.a) Diabetes?(Required) Yes No b) Heart or circulatory problems?(Required) Yes No c) Stomach or intestinal problems, such as ulcers?(Required) Yes No d) Any medical condition which causes difficulty sleeping?(Required) Yes No e) Chronic chest disorders where night time symptoms may be particularly troublesome?(Required) Yes No e) Chronic chest disorders where night time symptoms may be particularly troublesome?(Required) Yes No f) Any medical condition requiring medication on a strict timetable?(Required) Yes No g) Any medical condition where the timing of meals is particularly important?(Required) Yes No h) Any mental health problems which may be affected by night work?(Required) Yes No i) Any other medical condition which may affect your ability to work safely at night?(Required) Yes No j) Are you a new or expectant mother? (optional question)(Required) Yes No k) If you have worked at night before, did this cause any ill health?(Required) Yes No If 'yes' to any of the above, please give details i.e., when condition developed, is this new, how severe, its effect on you, how well controlled and treatment so far.Do you believe that any of these are made worse by night work?(Required) Yes No Yes No If 'yes', please give details:Would you like to discuss these with an Occupational Health Adviser?(Required) Yes No DeclarationI certify that all the answers given above are true to the best of my knowledge and belief. I understand that no medical details will be divulged without my permission to any person outside Occupational Health, but an opinion about my fitness for night work will be issued to management.(Required) Yes, I acknowledge. Typed Signature(Required)Date MM slash DD slash YYYY Signature(Required)
