CONFIDENTIAL QUESTIONNAIRE - CIVIL ENGINEERING WHITBY FIELD COURSE

OCTOBER 2015
To be returned to Judy Cowley in Chesham C2.34

Full Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date of Birth . . . . . . . / . . . . . / . . . . . Course/Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name and address of next of kin (to be contacted only in an emergency) . . . . . . . . . . . . . . . . . . . . .
...........................................................................
Telephone number of next of kin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name and address of your doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Your NHS No (I

f known) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Are you suffering from any of the following?

Asthma or Bronchitis
Heart condition
Fits, Fainting or Blackouts
Severe Headaches
Diabetes
Allergies to any known drugs
Any other allergies, e.g. Material, Food
Other illness or disability
Travel Sickness
Back, Knee or other joint problems
Any injury that might affect your performance

YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES

NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO

If the answer to any of these questions is YES, please give details here:
...........................................................................
...........................................................................
Have you received vaccination against Tetanus in the last five years

YES

NO

Are you receiving medical or surgical treatment of any kind from

either your Doctor or a Hospital - e.g. are you currently on any
medication?

YES

NO

YES

NO

Have you been given specific medical advice to follow

in an emergency?

If the answer to either of the last two questions is YES, please give the details here (including details of
condition and dosage of any medicines/tablets)
...........................................................................
Special Dietary Requirements
..............................................................................
..............................................................................
I have read and understood all the advance information pertaining to this course and in particular the Health and
Safety information.
Signed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Date . . . . . . . . . . . . . . . . . . . . . . . . . . . .