Sample Pre Enrolement Health Questionnaire - Free Download | Page 4
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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
4
GENERAL PRACTITIONER / FAMILY DOCTOR STATEMENT:
Your patient has applied to train in a branch of healthcare and has completed the attached pre-
enrolment questionnaire. Please complete the below.
STUDENT NAME:
DATE OF BIRTH:
ADDRESS:
Are you in possession of this patient’s complete medical history
YES / NO
Are you a relative of the applicant
(If so it is unethical to proceed and this form must be passed to another doctor who does not
have any close personal relationship with the student, in accordance with paragraph 5 of Good
Medical Practice)
YES / NO
According to these records and your knowledge of the applicant, do the answers given
in the questionnaire appear correct
YES / NO
Are you aware of any additional medical information which may be relevant to this
application (please provide details below):
YES / NO
Please complete the vaccination history as requested on this form.
Has this patient had any of these childhood illnesses
Chickenpox YES / NO Measles YES / NO Mumps YES / NO Rubella YES / NO
Please note: a medical examination is not required.
Hepatitis B vaccine.
Date: (1)
Date: (2)
Date: (3)
Date: (booster)
Anti HBs
Date:
Result:
iu/l
IGRA TB test
Date:
Result:
Mantoux
Date:
Result:
BCG Scar
Scar Seen: Yes / No Location:
BCG (TB vaccination)
Date:
Rubella (German measles) blood test
Date:
Result:
Measles blood test
Date:
Result:
source: ucl.ac.uk
