Ergonomic Assessment Prescreening Survey Ergonomic Assessment Prescreening Survey Full Name:* Email* Date of Birth: DD slash MM slash YYYY Please list any site of injury/concerns:Please list any orthopedic or musculoskeletal conditions that you have or have had:Please identify your current level of pain associated with the above injury/concerns on the scale below: 0 1 2 3 4 5 6 7 8 9 10 0=No Pain 10=Extreme PainHow long have you had this injury/concern? 1-4 days 1-4 weeks 1-3 months 6-12 months Longer than 12 months Do you take any medications? Yes No Please list your medicines and the condition they are taken forDo you ever experience: Chest pain Shortness of breath Faint or dizzy spells Has your Doctor ever said that you have a heart condition? Yes No Do you have high blood pressure? Yes No Have you had any surgery in the past year? Yes No Do you ever experience changes in bladder or bowel control? Yes No Do you ever experience weakness in your arms or legs? Yes No Do you ever experience numbness or tingling? Yes No Do you know any other reason you should not participate in physical activity? Yes No DetailsDo you currently smoke cigarettes on a regular basis? Yes No If yes, please provide details on quantity and frequency Do you currently consume alcohol on a regular basis? Yes No If yes, please provide details on quantity and frequency Are you receiving treatment from any other Health Care Professionals for any health conditions? Yes No If yes, please provide details on quantity and frequency DetailsDo you currently participate in structured physical activity? Yes No If yes, please provide details below:Activity Type: Duration: Frequency: Do you consent to participate in assessment recommended by Enriched Health Care? Yes No Do you consent for Enriched Health Care to share medical information with other contacts, including health care providers and employers where relevant? Yes No Date MM slash DD slash YYYY DISCLOSURE The information collected on this prescreening survey is collected for the purpose of an ergonomic assessment. It will form part of your employee record. If any information requested is not provided, it will impact on the assessment and recommendations. Our Privacy Statement is available by contacting Enriched Heath Care or visiting Enriched Health Care’s Website (www.enrichedhealthcare.com.au). If you have any queries about privacy, you can contact our Health Care Services Manager via email support@enrichedhealthcare.com.auCONSENT & DECLARATION I acknowledge and agree that the information provided by me in this form and any other information that I may subsequently provide may be disclosed to: Any entity involved in any restructure or transfer of Enriched Heath Care; Enriched Pty Ltd and any related bodies corporate of Enriched Heath Care; or Employees, agents or contractors or other service providers of Enriched Heath Care who reasonably require access to the information My employer For the purpose of enabling Enriched Health Care to complete an ergonomic assessment and any other assessments deemed reasonable and necessary By Signing below, you consent to participate in assessments administered by Enriched Health Care staff and consent for Enriched Health Care to share medical or other information with your employer, other contacts and health care providers where relevant? Signature Δ
