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DRS Medical Self-Assessments SF-08

Medical Self-Assessment Information

You are required to complete this Form as fully and accurately as possible. The completed forms are for the use of the company and will not be passed to a second party (with the exception of Network Rail and/or its auditing body). You are conditionally obligated at all times to inform the organisation of any changes to health, where a condition or ailment may cause impairment or restriction physically and/or mentally.

You must also inform your Manager if you are then required to take medication. This must be done by resubmitting this Form, which should be sent back to Head Office.

You have the right to withhold medical details if you do not wish to impart them to the organisation. However, as outlined above, to withhold information generally will result in complete liability of the signatory for any incident caused as a consequence of the impairment suffered.

In the event that you suffer from learning difficulties please advise your supervisor who will assist your understanding of the form. Tick the boxes where requested (Yes) ( No). The signatory and the person completing the form must be the same (no second party is permitted to complete the form on your behalf).

Assessments: Please answer ALL of the self-asessment questions.

   
Please select 'Yes' or 'No' to the following mendical questions.
1. Do you wear contact lenses?
This question must be answered.
2. Do you wear specticles?
3. Do you suffer blurred vision?  
Do you have any difficulty with your eyesight not including the use of glasses
4. Do you have difficulty hearing normal conversation?
5. Have you ever had blackouts, recurrent dizziness or any condition which may cause sudden collapse or incapacity? (If yes give details in comments)
6. Do you suffer headaches?
7. Do you suffer migraines?
8. Can you turn your head left and right without difficulty?
9. Have you encountered or do you encounter pains in your chest?
10. Do you suffer palpitations?
11. Do you have difficulty in moving over short distances including slopes, steps or rough ground?
12. Can you walk upstairs and inclines without difficulty or laboured breathing?
13. Do you have any phobias? E.g. darkness, heights. (If yes give details in comments)
14. Can you lift properly without pain or restriction?
15. Have you ever suffered a back injury? (If yes give details in comments)
16. Are you aware of Hand Arm Vibration Regulations?
17. Have you ever used air powered tools? (indicate in comments the type of tool)
18. Have you ever experienced during or after using those tools, numbness and/or tingling in your fingers?
19. Have you ever been exposed to high dust environments for any length of time?
20. Have you ever failed a medical or been refused any clearance on account of a medical screen?
21. Are you taking any prescribed medications? (give details in comments)
22. Do you have diabetes requiring insulin injections?
23. Do you suffer from epilepsy or fits?
24. Do you get discomfort or pain in the chest or shortness of breath on exercise such as climbing a flight of stairs?
25. Are you taking any medication that is causing drowsiness or dizziness?
26. Have you ever used drugs of abuse in the last 12 months?
27. Have you had any Alco related illness in the last 12 months?
28. Have you had any stress related illness in the last 12 months?
29. Have you been refused a driver’s licence because of ill health?
30. If you have an existing railway medical has there been any change to your medical condition since its issue?
31. Have you been refused or dismissed from employment for health reasons?
32. Any mental health problems that would affect your ability to work at night?
33. Any other medical condition which would affect your ability to work at night?
HAVS (Hand Arm Vibration Syndrome)
1. Did previous jobs involve the use of vibrating equipment?
2. Have you ever suffered from your fingers going white on exposure to cold?
3. Have you had any tingling or numbness in your fingers after using vibrating equipment?
4. Are you experiencing any problems with muscles or joints in your hands or arms?
5. Do you have any difficulty picking up small objects such as screws or nails?
6. Do any of your hobbies expose you to hand-arm vibration? If yes please give details?
7. If you answered yes to any question between 2 – 5 when did you first notice this?
 
If you suffer now how often does it occur?
Seasonal Occurrance?
Comments: You must include any details that may not have been specifically asked above, even if they may seem insignificant (Use additional sheet if required).

Declaration: I declare that the information given in this questionnaire is true and correct to the best of my knowledge and belief. I understand that if I have knowingly withheld information or given false information my employment may be terminated.

Signed by applicant: