Sample Pre Enrolement Health Questionnaire - Free Download | Page 5
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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
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Varicella (chickenpox)
History of chickenpox Y / N
Positive Blood Test Yes / No
MMR 1 Date:
MMR 2
Date:
Tetanus, Diphtheria & Polio
Vaccine 1
Vaccine 2
Vaccine 3
Vaccine 4
Vaccine 5
Date:
Date:
Date:
Date:
Date:
immunity to further infection.
Meningitis C
Date:
NOTES:
Thank you for your help. This form will only be accepted if it is signed by the responsible
registered medical practitioner with a legible practice stamp. Any fee required for completion of this
form is the responsibility of the applicant.
Practice stamp:
GP/Family Doctor Name:
GMC no:
Signed:
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A history of infection can only be accepted if the applicant grew up in a temperate climate
source: ucl.ac.uk
