Health Examinations
History or informed of:
Have you ever been diagnosed with Tuberculosis (TB)?
Yes
No
Have you ever had to take treatment for Tuberculosis (TB)?
Yes
No
Have you ever been inclose contact at work or at home with a person known to have Tuberculosis (TB)?
Yes
No
Have you ever been admitted to hospital and/or received medical treatment for an extended period for any reason (including for a major operation or treatment of a psychiatric illness)?
Yes
No
Do you suffer, or have you ever suffered, from mental health problems?
Yes
No
Have you ever been told you are HIV positive?
Yes
No
Have you ever had a positive Hepatitis B or Hepatitis C blood test?
Yes
No
Do you have or have you had cancer in the last 5 years?
Yes
No
Do you have high blood sugar / diabetes?
Yes
No
Do you have heart problems, including high blood pressure or a heart condition that you were born with?
Yes
No
Do you have a blood condition?
Yes
No
Do you have bladderor kidney problems?
Yes
No
Do you have aphysical or intellectual disability that makes it difficult for you to function independently (for example, to move around or learn) or be able to work full-time?
Yes
No
Are you, or have youever been, addicted to drugs or alcohol?
Yes
No
Are you taking any prescribed pills or medication (excluding oral contraceptives, over-the counter medication and natural supplements) ) If yes, please list these.
Yes
No
Are you pregnant?
Yes
No
Should be Empty: