BROWN’S HOTEL NIGHT WORKER ASSESSMENT FORM Brown's Hotel is committed to maintaining high standards of Occupational Health and to assist in doing so, asks all new night workers to provide details of their medical history. Please complete this questionnaire and submit at the end. The content of this questionnaire will remain confidential to the Occupational Health Department and no information will be divulged to non-medical personnel without your consent. The Group Occupational Health Advisor will review the questionnaire and may contact you to discuss the information it contains. The health of each new night worker will be considered individually and no decision concerning continuing employment will be made without medical examination. The Company retains the right to refer you to a Company nominated Doctor at its discretion. The Company requests your co-operation in obtaining further medical information from your Doctor or Specialist if necessary. In making any request the Company will comply fully with the requirements of the Access to Medical Records Act 1988.Name(Required) First Last Date of Birth:(Required) DD slash MM slash YYYY Email(Required) Contact number(Required)Position(Required)Name and address of your DoctorPlease 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 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) Yes No k) If you have worked at night before, did this cause any ill health?(Required) Yes No l) Do you have epilepsy, or a history of epileptic seizures?(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 confirm that my answers to all the questions in this medical questionnaire are correct and true and that have not knowingly omitted any fact or circumstance. I understand that any failure to disclose details of my medical history may prejudice my continued employment and also that the Company may refer me to a Company nominated Doctor at it’s discretion and hereby signify my consent to this arrangement.(Required) I consent. Typed Signature(Required)Date MM slash DD slash YYYY Signature(Required)
