Pre-employment questionnaire Enriched Health Care Pre-Employment Questionnaire This field is hidden when viewing the formReferrer Email Full Name:*Email* Date of Birth:* DD slash MM slash YYYY Photo IdentificationMax. file size: 20 MB.Please attach a photo of valid identification.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/concern 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 N/A 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 Risk Factors* High blood pressure High cholesterol Tightness in chest Shortness of breath Light headedness Dizziness No condition Respiratory* Asthma Emphysema Other pulmonary disease No condition Have you ever had an aneurysm (bleed/bulge in blood vessel wall) in your brain (cerebral) or abdomen?* Yes No In the last 3 months have you had a collapsed/punctured lung (pneumothorax)?* Yes No Have you ever coughed up blood from an unknown cause?* Yes No Have you ever had any unstable heart function (eg angina, recent GTN use)?* Yes No Have you had any eye surgery in the last 3 months (cataract, retinal reattachment, laser correction etc)?* Yes No Have you had any major surgery within the last 14 days (eg chest, throat or abdominal surgery)? Yes No Cardiovascular* Heart attack Stroke Arrhythmias Ischemic heart disease Heart surgery No condition Metabolic* Diabetes Type 1 (IDDM) Diabetes Type 2 (NIDDM) Gout Gastrointestinal condition Liver condition Kidney condition No condition Musculoskeletal * Broken bones Falls Osteoarthritis Rheumatoid Arthritis Osteoporosis No condition Neurological* Parkinson’s Disease Multiple Sclerosis Other No condition Other Cancer Epilepsy or seizures Pregnancy Vision problems Recent surgery Hearing/Ear Problems If you have ticked any of the above, please provide details:If you have never experienced any of the conditions above, please indicate here. Additionally, please indicate if you have known family history for any of the above conditions.Do you currently smoke cigarettes on a regular basis?* Yes No If yes, please provide details on quantity and frequency DetailsDo you currently consume alcohol on a regular basis? Yes No If yes, please provide details on quantity and frequency DetailsAre you receiving treatment from any other Health 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:DISCLOSURE The information collected on this application form is collected for the purpose of assessing your application for employment in the position for which you have applied or for another equivalent position for which you may have the skills and capabilities. It will form part of your employee record should you be successful. If any information sought is not provided your application may not be processed or assessed. 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 enquiries about privacy, you can contact our Health Care Services Manager via email workplace@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 Only those employees, agents or contractors or other service providers of Enriched Heath Care who reasonably require access to the information upon which I have signed a medical authority to release For the purpose of enabling Enriched Health Care to assess my application for employment in the position for which I have applied or for another position for which Enriched Health Care considers I may have the skills and capabilities. By Signing below, you consent to participate in assessments administered by Enriched Health Care staff and consent for Enriched Health to share medical or other information with your potential employer, other contacts and health care providers where relevant? Signature Δ
