Pre-employment questionnaire

Address: 3/133-135 Gordon St, Port Macquarie, NSW, 2444, AU
Telephone: (02) 6583 6900

Enriched Health Care Pre-Employment Questionnaire

Referrer Email
Full Name:*
Email*
Date of Birth:
Date Format: DD slash MM slash YYYY
Photo Identification
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 Pain
How 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 for
Do 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
Risk Factors
- High blood pressure
- High cholesterol
- Tightness in chest
- Shortness of breath
- Light headedness
- Dizziness
Respiratory
- Asthma
- Emphysema
- Other pulmonary disease
Cardiovascular
- Heart attack
- Stroke
- Arrhythmias
- Ischemic heart disease
- Heart surgery
Metabolic
- Diabetes Type 1 (IDDM)
- Diabetes Type 2 (NIDDM)
- Gout
- Gastrointestinal condition
- Liver condition
- Kidney condition
Musculoskeletal
- Broken bones
- Falls
- Osteoarthritis
- Rheumatoid Arthritis
- Osteoporosis
Neurological
- Parkinson’s Disease
- Multiple Sclerosis
- Other
Other
- Cancer
- Epilepsy or seizures
- Pregnancy
- Vision problems
- Recent surgery
- Hearing/Ear Problems
*If you have never experienced any of the conditions above, please indicate here (Please tick) 

Please indicate if you have known family history for any of the above conditions:
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
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 Professionals for any health conditions?
- Yes
- No
If yes, please provide details on quantity and frequency
Do 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.au
CONSENT & 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?
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