Standard Pre-Employment Medical Report

SECTION 1: MEDICAL QUESTIONNAIRE

To be completed by applicant and reviewed by Medical Practitioner

PERSONAL DETAILS

Surname: First Name:

Address:
Gender: Male Female Date of Birth:
Home Number: Mobile Number:
Email:
Proposed Job Role: Project:
Emergency Contact Emergency Contact
Name: Number:
Family Doctor Name
and Clinic Address:

CANDIDATE INSTRUCTIONS:
Please complete all sections of the Medical Questionnaire to the best of your knowledge and relevant to the applied position.
Leave comments boxes blank as all relevant answers will be discussed in further detail with the Medical Examiner.
Please Note:
The relevant worker’s compensation schemes have discretion to refuse to award compensation which would otherwise be
payable, where it is proved that the worker has, at the time of seeking or entering employment, wilfully and falsely represented
themselves as not having previously suffered from the disability, for which compensation is sought.

MEDICAL EXAMINER INSTRUCTIONS:

This section of the medical is to be completed by the applicant and all questions reviewed by the Medical Examiner. Please
comment on any YES answers in the comment boxes. Where previous injuries or illnesses are noted, please provide detail on
what the condition is, treatment received, duration of illness / injury / claim and whether this condition has resolved and/or is
likely to impact on the applicant’s ability to carry out the proposed job demands safely. If any conditions are identified that
require further medical investigation, please comment on your recommendations for further investigations or medical
management. Please complete a GP referral letter where further information or medical management is required for an
identified condition or injury.
On completion of the Medical Assessment, please check and comment on any risks identified on the Pre-Employment Medical
Summary page. To determine risk rating based on medical questionnaire, examination and functional assessment, please refer
to the Monadelphous Pre-Employment Medical Guidelines.

EMPLOYMENT HISTORY (At least 3; Must be completed by candidate)

Employer Position Dates (Month/Yr)
From: To:

From: To:
From: To:

From: To:
Have you previously been employed by Monadelphous? Yes No
If No, have you ever worked in a similar role to the one you are currently applying for? Yes No
Candidate Initials:

BMS-FRM-1194 Rev 4
Discipline: Human Resources Page 2 of 14
Division: Engineering Construction; Maintenance and Industrial Services Last printed: 04/05/202304/05/2023
 Standard Pre-Employment Medical Report
EMPLOYMENT HISTORY Cont.
Have you had significant exposure to any of the following?
Dust Yes No Chemicals Yes No
Asbestos Yes No Radiation Yes No
Noise Yes No Solvents Yes No

Have you ever had any issues or difficulties working at heights or in confined spaces? Yes No
Have you ever had any issues or difficulties working in a hot environment? Yes No

Is there any reason why personal protective equipment cannot be worn? Yes No

Have you had time off work in the last year for any illness or injury? Yes No
Have you ever had a Workers’ Compensation claim or any work-related illness or injury? Yes No
If Yes, What / Where / When:
Did you need time off work, If Yes, how long?
How long were you on light or alternate duties?
What treatment was required?
When did the condition completely resolve?
What was the date of claim closure?

Examiner Comments: (Please comment on all YES answers and document type, treatment and duration of any
previous injuries / illnesses / claims)

GENERAL HEALTH
Have you seen your Doctor in the last 6 months concerning your health? Yes No
Have you ever been admitted to hospital? Yes No

Do you or have you ever had any of the following conditions?

Persistent headaches or migraines Yes No Allergies Yes No

Kidney or bladder disease Yes No Hernia Yes No

Cancer or tumour of any type Yes No Thyroid or hormonal condition Yes No

Concussion or head injury Yes No Skin rashes /Dermatitis / Eczema Yes No

Hepatitis Yes No Tropical Diseases (e.g. Ross Yes No

River, Typhoid, Malaria, Dengue)

Have you ever been diagnosed with Diabetes? Yes No

Examiner Comments: (Please comment on all YES answers)

Candidate Initials

BMS-FRM-1194 Rev 4
Discipline: Human Resources Page 3 of 14
Division: Engineering Construction; Maintenance and Industrial Services Last printed: 04/05/202304/05/2023
 Standard Pre-Employment Medical Report
LIFESTYLE
How many drinks would you have on average per week?
What is the maximum number of drinks you would drink in one day?
Are you now or have you ever been dependant on drugs or alcohol? Yes No
Do you, or have you ever smoked? Yes No
If current / ex-smoker: Age Started: Age Stopped: Average cigarettes per day:
How many times per week do you normally participate in exercise?
What type of exercise do you regularly complete?
Please complete the following details for any medications (including over the counter) you are currently taking or
have taken in the past 6 months:
Name of Medication Condition Approximate duration taken
From: To:
From: To:
From: To:
From: To:
Examiner Comments:

MUSCULOSKELETAL HEALTH
Have you ever experienced any pain or discomfort in any of the following areas in the past 6 months?
Neck Yes No Back Yes No
Shoulder Yes No Hip Yes No
Elbow Yes No Knee Yes No
Hand or wrist Yes No Ankle or foot Yes No
Do you have OR have you ever had any of the following conditions?

Sciatica / Referred pain Yes No Unexplained feeling of pins Yes No

and needles
Osteoarthritis Yes No Osteoporosis Yes No
Rheumatoid arthritis Yes No Neck / lower back pain Yes No
Repetitive Strain Injury (RSI) Yes No Broken / fractured bones Yes No
Tennis elbow Yes No Tendonitis Yes No
Any other condition that affects your muscles, joints or bones? Yes No
Have you visited a Physiotherapist or Chiropractor in the last 12 months? Yes No
Examiner Comments: (Please comment on all YES answers with details on severity, recovery timeframes,
treatment and any other relevant clinical history)

Candidate Initials:

BMS-FRM-1194 Rev 4
Discipline: Human Resources Page 4 of 14
Division: Engineering Construction; Maintenance and Industrial Services Last printed: 04/05/202304/05/2023
 Standard Pre-Employment Medical Report
CARDIOVASCULAR HEALTH
Have you ever had any abnormal tests or pathology relating to heart health? Yes No

Have you been told that you have high cholesterol? Yes No
Do you have high blood pressure? Yes No
Do you have or have you ever experienced a heart attack or chest pains? Yes No
Have you ever undergone chest or heart surgery? Yes No
Examiner Comments: (Please comment on all YES answers)

RESPIRATORY HEALTH
Do you have OR have you ever experienced any of the following?
Bronchitis Yes No Hay Fever Yes No
Pneumonia Yes No Lung Cancer Yes No
Pleurisy Yes No Rheumatic Fever Yes No
Chronic Obstructive Pulmonary Yes No Tuberculosis Yes No
Disorder
Have you ever coughed up blood? Yes No
Do you ever feel short of breath without reasonable cause? Yes No
Do you regularly have a productive cough (bringing up phlegm from your chest) first thing in Yes No
the morning or during the day or night?
Have you ever had, or been told that you had Asthma? Yes No
If No, proceed to next section

If Yes, How many puffs of relieving medication (e.g. Ventolin) do you take in an average
week?
Have you ever been hospitalised for Asthma? Yes No

Have you required oral prednisolone, cortisone or oral steroids in the last three years? Yes No

Examiner Comments: (Please comment on all YES answers)

Candidate Initials:

BMS-FRM-1194 Rev 4
Discipline: Human Resources Page 5 of 14
Division: Engineering Construction; Maintenance and Industrial Services Last printed: 04/05/202304/05/2023
 Standard Pre-Employment Medical Report
EAR, EYE AND ORAL HEALTH
Do you have OR have you ever experienced any of the following conditions?

Hearing loss or difficulties Yes No Eye injury or condition Yes No

Tinnitus or ringing in ears Yes No Colour blindness Yes No
Recurring ear infections Yes No Dental problems Yes No
Dizziness or loss of balance Yes No Ear aches or discharge from ears Yes No
Do you wear glasses or contact lenses? Yes No
Examiner Comments: (Please comment on all YES answers)

GASTROINTESTINAL AND URINARY HEALTH

Do you currently experience any of the following conditions?
Changes in your bowel or urination Yes No Stomach ulcers, heartburn or Yes No
habits pancreatitis
Irritable Bowel Syndrome or other Yes No Kidney, Bladder or prostate Yes No
bowel conditions problems
Examiner Comments: (Please comment on all YES answers)

MENTAL HEALTH
Have you ever experienced stress, anxiety or depression that required medical Yes No
treatment or counselling?
Do you have or have you ever been diagnosed with a mental health condition? Yes No
Do you have or have you ever had any phobias e.g. travel, heights, confined Yes No
spaces?
Have you ever been prescribed or are you taking, antidepressants, sedatives or Yes No
sleeping tablets?
Have you ever been diagnosed with any other mental illnesses not listed above? Yes No
Examiner Comments: (Please comment on all YES answers)

Candidate Initials:

BMS-FRM-1194 Rev 4
Discipline: Human Resources Page 6 of 14
Division: Engineering Construction; Maintenance and Industrial Services Last printed: 04/05/202304/05/2023
 Standard Pre-Employment Medical Report
FATIGUE MANAGEMENT
Have you ever experienced sleep issues or excessive fatigue when completing shift Yes No
work?
Have you ever been diagnosed with sleep apnoea or used a Continuous Positive Yes No
Airway Pressure (CPAP) Machine?
Have you ever had chronic fatigue? Yes No
Do you ever take medication to help you sleep or remain alert or awake? Yes No
Examiner Comments: (Please comment on all YES answers)

VACCINATION HISTORY
Have you received vaccinations for the following:
Tetanus Yes No Date received:
Hep A / Hep B Yes No Date received:
Examiner Comments:

DECLARATION AND CONSENT

By signing below, I declare that all answers to these questions are correct and that I have not withheld any
information material to my application for employment. I agree that my application and the above statements
shall form the basis of such employment if a role is offered.
I consent to my Pre-Employment Medical assessment and associated relevant documentation being released
to Monadelphous and the Client or Company nominated Doctor and Health Team.

By signing below, I confirm I understand that:

• The purpose of gathering this medical information is to enable medical personnel to determine my
fitness to work
• The data will always be handled confidentially and in accordance with the Privacy Act (1988) and
related Australian Privacy Principles.
• I may be contacted directly by my prospective employer, the Assessing Doctor or Health Team to
discuss aspects of my assessment. In order to make a fitness for work determination, I may be
requested to supply additional information.

Name (Please print) __________________________________________________Date: ______________

Signature: ______________________________________________________________________________

Witness to Signature: _____________________________________________________________________

Thank you. Please return form to receptionist now

BMS-FRM-1194 Rev 4
Discipline: Human Resources Page 7 of 14
Division: Engineering Construction; Maintenance and Industrial Services Last printed: 04/05/202304/05/2023