Occupational Health Medical History Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Job Title
Department
Medical History
Have you ever had any of the following? (Check all that apply)
Asthma
Diabetes
Heart Disease
High Blood Pressure
Epilepsy
Allergies
Other
Please list any medications you are currently taking
Do you have any disabilities or health conditions we should be aware of?
Work Related Factors
Have you previously suffered any work-related injuries or illnesses?
Are you currently experiencing any symptoms related to your work?
Immunisation History
Please list your immunisations (e.g., tetanus, hepatitis B, etc.)
Additional Information
Is there any other information you would like to share?
Signature
Date