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PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE

The aim of the Pre-Employment Medical (PEM) Questionnaire is to ensure that applicant’s physical and other related abilities are matched to the medical and fitness standards for the particular duties of a job.
Pre-Employment Medical Questionnaires (PEM’s) are necessary to determine that:

There is not risk of aggravating a pre-existing medical condition
The applicant is able to productively carry out the duties of the position safely
The applicant should not, because of a medical condition, increase risk to other workers, equipment, products or the general public.

CONFIDENTIALITY
The Pre-Employment Questionnaire is treated as a confidential document and access is limited to a ‘need to know’ basis. In the event of you being employed, Advanta Commercial Furniture will retain this form on a confidential file and reserve the right to refer to the information in the event of an accident, sickness, injury or claim for worker’s compensation. The information may also be used for other purposes, if so required by law.

IMPORTANT NOTICE
To assist Advanta Commercial Furniture in assessing your medical fitness for employment, you must answer the questions contained in this questionnaire truthfully and to the best of your knowledge.

Failure to disclose any relevant matter relating to your health may result in your not being employed by the employer or, if already employed by the employer, your employment may be affected and rights to workplace compensation compromised.

PEM

Personal Details
Name*
First Middle Last
Address*
Suburb*
State*
Postcode*
Date of Birth*
DD dot MM dot YYYY
MEDICAL HISTORY
Have you lost any time from work in the last 12 months due to illness or injury?*
- Yes
- No
If yes, please state for what reason
Are you currently taking, or in the past two years have taken any medication?*
- Yes
- No
If yes, please state
Do you have any known allergies?*
- Yes
- No
If yes, please state
Are you taking or do you need to take any medication for the known allergy?*
- Yes
- No
- N/A
If yes, please state
Any additional information in relation to the allergy?
For how many hours at a time can you stand and / or walk ?*
- Less than 1 hour at a time
- 1 – 2 hours
- 2 -4 hours
- 4 – 6 hours
- 6 – 8 hours
- more than 8 hours at a time
Answer each question below
1. Asthma, Bronchitis, Pleurisy, Coughing, Breathlessness, Tuberculosis (TB) or other lung complaints?*
- Yes
- No
Comments
If applicable
2. Coughing up blood*
- Yes
- No
Comments
If applicable
3. Hay fever, sinusitis, severe headaches*
- Yes
- No
Comments
If applicable
4. Heart disease, heart attack, heat complaints*
- Yes
- No
Comments
If applicable
5. Chest pain*
- Yes
- No
Comments
If applicable
6. Blood pressure, heart irregularities, rheumatic fever*
- Yes
- No
Comments
If applicable
7. Anaemia, Bleeding disorders, other disorders of the blood*
- Yes
- No
Comments
If applicable
8. Vascular or other blood vessel disorders*
- Yes
- No
Comments
If applicable
9. Arthritis*
- Yes
- No
Comments
If applicable
10. Bone or joint problems*
- Yes
- No
Comments
If applicable
11. Broken bones, factures or dislocations*
- Yes
- No
Comments
If applicable
12. Any joint pain or injury*
- Yes
- No
Comments
If applicable
13. Muscle, tendon or ligament problems*
- Yes
- No
Comments
If applicable
14. Pains, aches, numbness or weakness in the neck, shoulders, arms, hands or fingers*
- Yes
- No
Comments
If applicable
15. Feet, ankle, knee problems*
- Yes
- No
Comments
If applicable
16. Strains or sprains*
- Yes
- No
Comments
If applicable
17. Back complaint / back injury*
- Yes
- No
Comments
If applicable
18. Gout*
- Yes
- No
Comments
If applicable
19. Hernia*
- Yes
- No
Comments
If applicable
20. Stomach or duodenal ulcers*
- Yes
- No
Comments
If applicable
21. Chronic indigestion*
- Yes
- No
Comments
If applicable
22. Intestinal or bowel trouble*
- Yes
- No
Comments
If applicable
23. Hepatitis*
- Yes
- No
Comments
If applicable
24. Diabetes, thyroid problems, gall bladder problems or other gland problems*
- Yes
- No
Comments
If applicable
25. Any skin conditions*
- Yes
- No
Comments
If applicable
26. Head injury*
- Yes
- No
Comments
If applicable
27. Epilepsy, fainting, fits, blackouts or dizzy spells*
- Yes
- No
Comments
If applicable
28. Chronic headaches or migraines*
- Yes
- No
Comments
If applicable
29. Vision problems that cannot be corrected by prescription glasses*
- Yes
- No
Comments
If applicable
30. Ear conditions, hearing loss, deafness or tinnitus (ringing in ears)*
- Yes
- No
Comments
If applicable
31. Nervous disorders, mental or psychiatric problems, depression*
- Yes
- No
Comments
If applicable
32. Any sporting, vehicle or work-related illness or injury*
- Yes
- No
Comments
If applicable
33. Have you worked in any noisy conditions*
- Yes
- No
Comments
If applicable
34. Have you worked in any dusty conditions*
- Yes
- No
Comments
If applicable
35. Do you have a fear of heights or confined spaces*
- Yes
- No
Comments
If applicable
36. Any other illness, injury, health condition or operation not mentioned*
- Yes
- No

Further details

Duration and dates of condition	Current status

Have you been vaccinated against:
Hepatitis A*
- Yes
- No
Hepatitis B*
- Yes
- No
Hepatitis C*
- Yes
- No
Are you a current smoker?*
- Yes
- No
If yes, average per day:
If not a current smoker, have you ever smoked?*
- Yes
- No
If yes, when did you give up?
For how many years did you smoke?
Do you drink alcohol?*
- Yes
- No
Average per week?
Are you involved in any sporting activities or hobbies?*
- Yes
- No
If yes, please list:
Do you have any condition or problem that may impact upon your ability to perform your job?*
- Yes
- No
Please provide details, below.
Clinic Name and Address:
Doctor:
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Drop files here or

Max. file size: 128 MB.
DECLARATION
I hereby declare that: - I have read and understood the conditions of this form. - I understand that the information I provide will be retained on my employee file and that the employer reserves the right to access and use the information in the event of any accident, injury, sickness or claim for workers compensation or for any other reasonable purposes, if so required by law. - I consent to Advanta Commercial Furniture and its medical representatives obtaining or exchanging further medical information from my treating doctors or other health practitioners, if required for the purposes of this assessment. - My answers relating to my medical and employment history are true and complete to the best of my knowledge. Furthermore there is nothing else regarding my health, well being ,or ability to carry out my potential role which Advanta Commercial Furniture or its medical advisers may need to know to assess me for the position(s) for which I have applied. - I am fully aware that if I fail to disclose any relevant matter relating to my health, which renders me incapable of properly fulfilling the duties of the position, the employer may not employ me or if already employed by the employer, my employment may be summarily terminated. - I understand and agree that this report and any related health information provided may be supplied to Advanta Commercial Furniture and its medical advisors.
SIGNED*
Date*
DD dot MM dot YYYY
_________________________________________*
- I understand and agree

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PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE

PEM

Personal Details

MEDICAL HISTORY

Answer each question below

Have you been vaccinated against:

DECLARATION

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