Medical Declaration Update

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Last Name*
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Email*
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Medical Declaration

Do you have or have you ever had:

Allergies, including to drugs; animals; bee stings; pollens; grass; food; rubber; chemical*
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Heart conditions (heart attacks; angina; high/low blood pressure; murmur; palpitations; chest pain, etc)*
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Stroke; clots in legs or lungs; excessive bleeding or bruising; DVT; varicose veins:*
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Nervous System Disorder (paralysis; blackouts; dizzy spells; fainting or attacks of unconsciousness; epilepsy; muscular weakness; numbness in fingers/hands; coordination problems):*
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Eye conditions (restricted vision; Glaucoma Iritis; colour blindness; other)*
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Field is required!
Ear conditions; restricted hearing; tinnitus; ear infections; hearing loss; hearing difficulties*
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Skin conditions (Eczema; Dermatitis; rash; Psoriasis; recent skin infection; Skin Cancer)*
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Lung Conditions (Asthma; Bronchitis; Pleurisy; Tuberculosis; coughing up blood; persistent cough; chest complaints; shortness of breath; Silicosis; Asbestosis; other)*
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Digestive system conditions (Colitis; frequent diarrhoea; Gastric/Duodenal Ulcer; IBS; Hepatitis; Liver complaints / Jaundice; pancreatitis)*
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Migraine; persistent headaches; head injury; concussion*
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Sleep disorder; Issues with sleep or excessive fatigure when performing shift work?*
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Chronic fatigue lasting greater than 6 weeks*
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Field is required!
Take medication to help you sleep or remain alert or awake?*
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Rheumatic fever*
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Field is required!
Kidney / Bladder conditions (kidney stones; urinary infection; prostate problem)*
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Arthritis, gout, joint pain or swelling*
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Field is required!
Feet problems, ankle problems or foot pain when standing or walking*
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Field is required!
Knee injury, swelling or pain*
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Field is required!
Shoulder pain, tendonitis or frozen shoulder*
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Back / Neck problems (disc problems; prolonged back/neck pain; whiplash; sciatica or leg pain)*
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Field is required!
Broken bones or fractures*
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Repetitive strain injury such as tendonitis, tennis elbow, golfers elbow, Carpal tunnel syndrome or any other over use condition*
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History of Tropical / Infectious Diseases including Malaria; Hepatitis; Tuberculosis (TB), Dengue Fever*
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Diabetes or thyroid problem (over/under active thyroid)*
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Cancer or other tumours*
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Mental Illness / stress (nervous breakdown; mental fatigue; anxiety; depression; panic attacks; self-harm; significant sleep disturbance; eating disorders; fear; phobias to travel or confined spaces; schizophrenia; bipolar)*
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A pace maker or any other implantable device*
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Are you receiving medical treatment at the present time that an employer should know about?*
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Do you currently have any work restrictions certified by a Doctor?*
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Do you take regular medication?*
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Other conditions that may require medical management onsite (relevant to remote locations)*
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Hold a conditional Driver's License (with restrictions or conditions due to a medical condition), or have a condition you should report to the licensing authority?*
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Work Related Health History

Have you ever had (or currently have) any injury / illness / disease, whether physical or mental, that could affect your ability to perform this role?*
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Have you ever experienced conflict or stress at work that required medical treatment or counselling?*
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Have you ever left, or been denied a job on health grounds?*
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Have you ever been advised for medical reasons, not to do night work, shift work, or any other kind of work?*
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Have you ever lodged a Workers Compensation Claim?*
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Do you have a current Workers Compensation Claim?*
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Vaccination History - Have you had the following?

Had Chicken Pox
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Had Mumps
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Had Measles
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Vaccination History - Have you had or are you willing to get the following vaccinations if required?

Whooping Cough Vaccination
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Covid-19 Vaccination
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Hep A Vaccination
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Hep B Vaccination
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Flu Shot
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Social History

Do you currently smoke?*
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Extra Details - Do you have difficulties with the following activities?

Kneeling or crouching*
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Field is required!
Climbing stairs or ladders*
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Repetitive movement of hands or arms*
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Working in extremes of temperature*
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Concentrating on a task*
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Reading ordinary print*
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Hearing a normal conversation*
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Walking on rough or uneven ground*
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Standing or sitting for 2 hours or more*
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Lifting or bending*
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Gripping firmly with both hands*
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Confined spaces*
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Shift work*
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Turning your head rapidly*
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Stress Assessment

Given the nature of this role (working with complex youth autonomously), do you feel you have the emotional, mental, physical, and psychological fitness to perform this role?*
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If no, please provide additional information*
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Fatigue Assessment

Have you worked in a previous role that requires at least 10 hours of concentrated effort without a break?*
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If no, please provide additional information regarding how you believe you would cope*
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I hereby certify that to the best of my knowledge and belief, the answers provided by me are true and correct*
I understand that any false or misleading information may result in termination of employment. I understand that I may also be required to provide copies of medical assessments/medical clearance/doctors/medical specialists letters during employment and on termination.
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