Pre-Employment Health Assessment Please print, scan & email to convenor/hiring manager or bring to interview

Section 1 (pages 1 – 2) – Applicant to complete - Please print clearly in block letters, completing all sections.

APPLICANT’S DETAILS
Family name First name

Middle name Date of birth (DD-MM-YYYY) Male Female

- -
Street address

Suburb State Postal Code

Daytime contact phone number (Home / Work) Mobile phone

( )
Medication History

Are you taking any prescription medication? Yes / No (please circle)

If YES: Type Frequency Type Frequency

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MEDICAL HISTORY DETAILS NB: For any ‘yes’ responses provide further details on page 2.

1 Have you been hospitalised for any reason in the last 12 months? * Yes No

2 Are you being treated by a doctor for any illness/injury? * Yes No

3 Have you previously ceased work with another employer because of illness/injury/poor health? * Yes No

Do you have, or have you EVER had? NB: For any ‘yes’ responses provide further details on page 2.
4 Back injuries and/or problems? * Yes No 13 Diabetes or pre-diabetes condition? * Yes No

Heart conditions? e.g. chest pain heart

5 Neck injuries and/or problems? * Yes No 14 * Yes No
attack, palpitations.
Stroke, mini stroke or TIA (transient
6 Shoulder injuries and/or problems? * Yes No 15 * Yes No
ischemic attack)?
Fainting spells, blackouts, dizziness or
7 Knee injuries and/or problems? * Yes No 16 * Yes No
funny turns?

8 Wrist injuries and/or problems? * Yes No 17 Epilepsy, convulsions, seizures or fits? * Yes No

Any other problem(s) resulting in a

9 Elbow injuries and/or problems? * Yes No 18 * Yes No
sudden loss of consciousness?
Any other problems affecting general
10 Arthritis or joint replacement? * Yes No 19 * Yes No
strength/fitness?
Depression, anxiety or any other
11 Any amputation of hand, foot or limb? * Yes No 20 * Yes No
psychiatric condition?
Substance abuse or alcohol
12 Any other musculoskeletal problem(s)? * Yes No 21 * Yes No
dependence or abuse?
* For any ‘yes’ answers complete the questions on the next page. If needed, ask the doctor for help at the time of your examination.

Page 1 of 2 Applicant Name: ……………………………………

Provide details for all ‘yes’ answers in Questions 1 – 21 by answering all applicable questions in rows A – M.
Question No. (from 1-21) Q.___ Q.___ Q.___ Q.___ Q.___
A. Date condition first
started.
B. What was/is the
condition?

C. Which exact part of the

body was/is affected?

D. What was/is the

frequency of attacks or
symptoms?
E. What was/is the
severity?
(mild/moderate/severe)
F. What was/is the duration
of attacks or symptoms?

G. If you were unable to

work or perform
activities provide dates
and duration

H. If a hospital stay was

required, provide date(s)
and duration.
I. Are you still receiving
treatment? If so, what?

J. Date treatment/
medication ceased?

K. When did you last have

any symptoms?

L. Degree of recovery (%)

DECLARATION
I hereby declare that all the information I have provided in this document is true and accurate.

I understand that this information shall be forwarded to NSW Health Pathology for the purposes of:
 Assessing my suitability to meet the job demands of the position for which I am seeking employment, and
 Complying with Work Health and Safety and Workers Compensation legislation and guidelines.
I understand that if the information provided by me is false or misleading, that this may result in termination of my
application or termination of my employment.

I understand that this information will not be used or disclosed for a purpose other than the purpose for which it was
collected, without my consent.

I understand that I am able to access health information held about me by NSW Health Pathology, as per the NSW
Health Records and Information Privacy Act 2002, and it successors.

I declare that the information I have provided is correct.

Name ____________________________________________ Date of birth ________________
Phone or Email ________________________________________________________________
Position Applied for _____________________________________________________________
Signature _______________________________________ Date _________________________

Page 2 of 2
Applicant Name: ……………………………………