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Sample Pre Enrolement Health Questionnaire
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
2
Yes
No
1. Do you have any eyesight problems not corrected with glasses
2. Do you have any hearing problems Details :
3. Are they corrected with a hearing aid
4. Do you have any other problems with communication e.g. speech, reading, spelling
5. Do you have any difficulty with walking, standing, bending, lifting or other movements
6. Do you have any difficulty with co-ordination of your movements e.g. writing, dressing
7. Have you ever had any mental health problem (including anxiety, depression, self-harm,
eating disorders or addictions)
8. Have you ever been treated by a psychiatrist, psychologist, or counsellor
9. Have you ever had drug or alcohol problems or any substance dependence
10. Have you ever had any disorder that affects your memory or ability to concentrate
11. Have you ever had blackouts, epilepsy, or any condition causing loss of consciousness
12. Have you been absent from work or study due to illness in the last two years
13. Do you currently have any health problems, including psychological problems, or are you
awaiting surgery
14. Are you presently receiving any prescribed medication, treatment or therapy other than
contraception
15. Do you have any health condition caused or made worse by work or study
16. Do you have any disability
1
, learning difficulties or other health condition not mentioned
above that may require additional help or support to undertake your studies
17. Have you lived outside of the UK in
the past 5 years$
$
!
Yes
No
If YES please complete:!
!
COUNTRY NAMEs & DATES
18. Have you ever lived with anyone who has tuberculosis (TB)
19. Have you ever worked or studied in an area where tuberculosis (TB) is prevalent
20. In the last three weeks have you experienced a persistent cough, coughing up blood,
profuse night sweats, unexplained fever, or unexplained weight loss
21. Do you have or have you had any other health issues that have not been mentioned
above, about which you would like to provide further details
Equality Act 2010 You would be regarded as disabled if you have an impairment that has lasted or is likely to last
for more than one year and is sufficient to impair normal day-to-day activities.
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source: ucl.ac.uk
Sample Pre Enrolement Health Questionnaire