Sample Pre Enrolement Health Questionnaire - Free Download
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UCL Occupational Health Service
University College London Gower Street London WC1E 6BT
Tel: +44 (0) 20 7679 2802 Fax: +44 (0) 20 7209 0256
www.ucl.ac.uk/hr/occ_health
Accredited by the Faculty of Occupational Medicine
as a Safe, Effective, Quality OH Service
1
UCL HUMAN RESOURCES DIVISION
OCCUPATIONAL HEALTH SERVICE
CONFIDENTIAL: UCL MEDICAL SCHOOL HEALTH QUESTIONNAIRE
First Name:
Family Name:
Intake Year:
Course:
DOB:
Address (UK):
Email:
Mobile / cell:
Other tel:
HEALTH INFORMATION
The questions in this form are designed to determine, in terms of medical fitness, your suitability to
undertake your studies as a medical student. They are also designed to assess the level of
support that might be necessary to facilitate your training.
ONCE COMPLETED, YOU ARE REQUIRED TO HAVE THIS FORM VALIDATED BY YOUR
GENERAL PRACTITIONER / FAMILY DOCTOR OR EQUIVALENT, THEN SCAN AND SEND AS
A SINGLE DOCUMENT (PDF) TO uclstudentoh@ucl.ac.uk
Most health problems or disabilities should not prevent you from undertaking studying as a Medical
Student, but the University has to be sure that you do not have an impairment that could make it
impossible for you to learn, or perform, the skills necessary for you to work safely with patients.
If UCL Occupational Health Service requires further details, we will contact you, and where
necessary, obtain your consent, to contact your treating doctor(s). Occupational Health
professionals are bound by the same rules on medical confidentiality as other health professionals
in the UK. Detailed medical information will not be disclosed without your consent, unless there is a
risk of harm to yourself or others.
Please answer YES or NO for each question. If you answer YES you must give information on
when this occurred, how it affects you, if it still exists, and any treatment that you require in the box
on page 6.
source: ucl.ac.uk
