Enriched Health Care Pre-Employment Questionnaire Referrer Email Full Name:*Email* Date of Birth: Date Format: DD slash MM slash YYYY Photo IdentificationPlease 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:0123456789100=No Pain 10=Extreme PainHow long have you had this injury/concern?1-4 days1-4 weeks1-3 months6-12 monthsLonger than 12 monthsDo you take any medications?YesNoPlease 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?YesNoDo you have high blood pressure?YesNoHave you had any surgery in the past year? YesNoDo you ever experience changes in bladder or bowel control?YesNoDo you ever experience weakness in your arms or legs? YesNoDo you ever experience numbness or tingling?YesNoDo you know any other reason you should not participate in physical activity?YesNoRisk 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?YesNoIf yes, please provide details on quantity and frequency Do you currently consume alcohol on a regular basis?YesNoIf yes, please provide details on quantity and frequency Are you receiving treatment from any other Health Professionals for any health conditions?YesNoIf yes, please provide details on quantity and frequency Do you currently participate in structured physical activity?YesNoIf yes, please provide details below:Activity Type:Duration:Frequency:How did you hear about Enriched Health Care?COVID-19For your safety as well as that of the community, the following question group is designed to assess your risk regarding COVID-19. Please note that COVID-19 is the specific name of the current coronavirus pandemic, due to the existence of multiple forms of coronavirus, the following question set will refer to it as COVID-19 Social Distancing & Hygiene Please confirm that you are practising the following social distancing rules. I am: Maintaining a minimum distance of 1.5 metres from people, when in public Practising good hygiene and washing my hands regularly Coughing and sneezing in my elbow or a tissue that is disposed of appropriately Avoiding handshakes and other contact greetings Regularly cleaning surfaces that are touched including but not limited to bench tops, door handles, light switches etc Limiting travel and outings as directed by government and health authorities Have you downloaded the CovidSAFE app?YesNoHave you had any cold or flu like symptoms (including but not limited to shortness of breath, difficulty breathing, coughing, fever, chills, sore throat, fatigue) over the last 14 days?YesNoPlease select symptoms which you have had: Shortness of breath or difficulty breathing Coughing Fever or high temperature (over 37.5) Fatigue Sore Throat Muscle Pain Headache Chills Other Have you been in contact with anyone displaying cold or flu like symptoms (including but not limited to shortness of breath, difficulty breathing, coughing, fever, chills, sore throat, fatigue) in the last 14 days?YesNoHave you travelled through or to a location that has had confirmed COVID-19 cases in the last 14 days? Please refer to the following NSW Government link for details https://www.nsw.gov.au/covid-19/latest-news-and-updatesYesNoIf you answered yes to the previous question, please list location(s)Have you been in contact with anyone who has travelled through or to a location that has had confirmed COVID-19 cases in the last 14 days? Please refer to the following NSW Government link for details https://www.nsw.gov.au/covid-19/latest-news-and-updatesYesNoIf you answered yes to the previous question, please list location(s)Have you travelled internationally in the past 30 days?YesNoHave you been on a cruise ship in the past 30 days?YesNoWhat date did you disembark?Please list any countries you've visited or passed through in the last 30 daysWhat date did you return to your current location?Have you been in close contact with anyone who has travelled internationally in the past 30 days? (Close contact is considered 15 minutes or more)YesNoDid the international traveller complete a 2 week isolation period before coming into contact with you?YesNoHave you visited any other state, territory or region in the last 14 days?YesNoPlease list any other state, territory or region in the last 14 daysHave you been in contact with anyone you know has tested positive to COVID-19 or who is currently undergoing COVID-19 testing?YesNoHave you been submitted to testing to determine if you have COVID-19?YesNoIf yes, what date were you submitted to COVID-19 testing? Date Format: MM slash DD slash YYYY If you have been submitted to COVID-19 testing, have you been informed as to the results of these tests?YesNoHave you been diagnosed with COVID-19?YesNoIf you have been diagnosed with COVID-19, what date were you diagnosed?If you have been diagnosed with COVID-19, were you hospitalised for treatment of COVID-19?YesNoIf you have been diagnosed with COVID-19, have you completed self-isolation or medical isolation for a period of 14 days or more?YesNoHave you been in self-isolation during the last 30 days due to any of the following reasons; illness, showing symptoms of COVID-19, exposure to someone who showed symptoms or tested positive to COVID-19, international travel, being in close contact with someone who travelled internationally? (Do not select yes for self-isolation due to government mandated population isolation)YesNoIf you have been in self-isolation, is this ongoing?YesNoHow many days did you self-isolate for?Have you received a medical clearance?YesNoDISCLOSURE 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
