WELLINGTON SHIRE COUNCIL PRE- EMPLOYMENT/ CONTINUATION HEALTH ASSESSMENT

Please take this completed form to your pre-employment medical appointment. To arrange an appointment contact Desailly Street Medical Centre on 5144 5766. As a new staff member you are required to attend a pre-employment medical within the first month of your commencement with Council.

Privacy Note: The personal information requested on this form is being collected by Council for Human Resources – employment record purposes. The personal information will be used solely by Council for that primary purpose or directly related purposes. The applicant understands that the personal information provided is for the Human Resources – employment record purposes and that they may apply to Council for access and/or amendment of the information.

Section A – Medical History Date…………………..

Surname……………………………….. First Names………………………………………

Address…………………………………………………………………………………………………

Date of Birth……………………………

Proposed Occupation/Position………………………………………………………………………

Occupational History

Previous Employers Length of Employment Industry Type Occupation/Position

1 An audiogram is required for each employee

Are you being treated by a doctor for any illness? Yes/No ……………………

Are you taking any medicines, tablets, or other treatment now? Yes/No…………………….

When was your last remembered tetanus injection? Year………………………..

Has your weight altered much in the past year? Yes/No…………………….

Have you lost time from work because of illness or injury? Yes/No…………………….

Have you ever had a disease or injury at work? Yes/No…………………….

Have you ever been exposed to excessive noise at home, work or sport (machinery, vehicles, chainsaws, music, shooting) without adequate hearing protection? Yes/No…………………….

Do you consume alcohol? Yes/No If yes – Type…………………………………. Daily Amount…………………………………

Have you ever smoked? Yes/No If yes – Current smoker Yes/No Years smoking?………………………………. Daily amount…………………………………..

Revised December 2014 Have you ever had/suffered from?

Yes No Yes No Tuberculosis Blackouts, faints Frequent headaches, Hay Fever migraines Asthma/Wheezing Head injury, concussion Heart trouble Fractured bones Chest Pain Joint injury Palpitations Joint pain, Arthritis, Gout High Blood Pressure Back pain, back injury Stomach or duodenal ulcer Sciatica Passing or vomiting blood Neck Pain Jaundice or Hepatitis Muscular pain, Fibrositis Hernia RSI, Overuse Syndrome Tenosynovitis, Tennis Allergies elbow Foot trouble, shoe Blood Transfusion problems Diabetes Eye trouble Malaria, Tropical disease Hearing Loss Dermatitis/Eczema Earache, discharging ears

Please list any illness, injury or operation not listed above…………………………………………… ………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………….

I hereby certify that the foregoing particulars are to the best of my knowledge correct. I authorize the examination to appropriate officers of the Wellington Shire Council.

Signed …………………………………… Date………………………

Revised December 2014 Section B – Medical Examination

Name……………………………………………………….

Height……………………………….cm Weight……………………………….kg Blood Pressure……………………../……………………….mm.Hg Pulse………………………….bpm……………………….(reg./irreg.) Visual Acuity…………………… L /6 (unaided) L /6 (aided) R /6 (unaided) R /6 (aided) Visual Fields………………………normal/abnormal Urine……………………………… Glucose………………… Protein………………….. Blood…………………… Hearing whispering voice……………L……………...R……………… Attached copy of Audiogram

General Appearance……………………………………………………………………….…. Is applicant overweight or underweight?………………………………………………….… Abnormality of gait, movement, co-ordination, speech……………………………………. ……………………………………………………………………………………………………

DETAIL Eczema/Dermatitis yes/no………………………………………... Other skin abnormality yes/no………………………………………… Abnormal lymph nodes yes/no………………………………………… Thyroid abnormality yes/no………………………………………… Nose or throat abnormality yes/no………………………………………… Evidence of lung abnormality yes/no…………………………………………. Cardiac enlargement yes/no…………………………………………. Abnormal peripheral pulses yes/no…………………………………………. Varicose Veins yes/no…………………………………………. Mouth abnormality yes/no…………………………………………. Abnormal abdominal organ yes/no…………………………………………. Hernia yes/no………………………………………….

LOCOMOTOR SYSTEM Spinal scoliosis/kyphosis yes/no………………………………………….. Scar of back/previous surgery yes/no………………………………………….. Spinal movements: Cervical………………………………………. Lumbar………………………………………... If restricted SLR….……R……….L………... Joint movements: Upper limb……………………………………. Lower limb……………………………………. Any other joint abnormalities yes/no………………………………………….. Any abnormal reflexes yes/no…………………………………………... Muscle wasting yes/no…………………………………………… Abnormal tone, or tremor yes/no…………………………………………… Evidence of muscle or tendon disorder yes/no……………………………………………

Revised December 2014 Section C – Medical Practitioner – Pre-Placement Recommendations

The abovementioned is considered suited to the duties as described within the specifications of the duties for the proposed occupation. Yes/No

Remarks………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ……………………………………………………………………………………………………………

Do you consider further examination is necessary? Yes/No

Any other comments? Yes/No

…………………………………………………………………………………………………………….. …………………………………………………………………………………………………………….. …………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………..

Date……………………………………… Signed…………………………………………….

Please return the Medical Report under sealed envelope to Human Resources, Sale Service Centre, 18 Desailly Street (PO Box 506), Sale 3850.

PLEASE MARK YOUR ENVELOPE “STRICTLY CONFIDENTIAL”

Revised December 2014