Form-Health Questionnaire NSW Ambulance

Health Questionnaire (365 Testing)

Section 1 - Examinee Information

Examinee to Complete

Name(Required)

First Last

Date of Birth(Required)

Position (or position applied for)(Required)

Address(Required)

Daytime Phone

Mobile(Required)

Gender

Male

Female

Employer

Medical History

1. Are you currently attending a health professional for any illness or injury?

Yes

2. Are you taking any regular medication?

Yes

3. Have you ever had any operations or accidents or been in hospital?

Yes

Do you suffer from or have you ever suffered from:

4. High blood pressure

Yes

5. Heart disease

Yes

6. Chest pain, angina

Yes

7. Any condition requiring heart surgery

Yes

8. Palpitations / irregular heartbeat

Yes

9. Lung problems (e.g. asthma, bronchitis)

Yes

10. Head injury, spinal injury

Yes

11. Seizures, fits, convulsions, epilepsy

Yes

12. Blackouts or fainting

Yes

13. Stroke

Yes

14. Dizziness, vertigo, problems with balance

Yes

15. Double vision, difficulty seeing, or difficulty adapting to changing light conditions

Yes

Do you suffer from or have you ever suffered from:

16. Colour blindness

Yes

17. Memory loss or difficulty with attention or concentration

Yes

18. Diabetes

Yes

19. A psychiatric illness or nervous disorder

Yes

20. Any other health complaints

Yes

Do you suffer from or have you ever suffered from:

21. Neck

Yes

22. Back

Yes

23. Shoulders

Yes

24. Elbows / wrists / hands

Yes

25. Hips

Yes

26. Knees

Yes

27. Ankles / feet

Yes

28. Have you had any other health complaints

Yes

Paramedics only (not to be completed by Applicants)

29. Have you had difficulty completing any of your tasks at work?

Yes

Smoking

30. Do you now smoke, or have you ever smoked?

Yes

a. If yes, when did you start?

b. When did you stop?

c. What did/do you smoke?

d. How many/how much per day?

Illicit drugs

31. Do you use illicit drugs?

Yes

Physical Activity

32. Do you do any regular exercise?

Yes

a. If yes -What type? (e.g. walking, running, swimming, sport)(Required)

b. How many times per week?(Required)

c. For how long each time?(Required)

d. Total exercise > 150 mins per week?

Yes

Family History

33. Has a member of your immediate family (parent, brother, or sister) been diagnosed with diabetes?

Yes

34. Does a member of your immediate family (parent,brother, or sister) have a history of premature (atage < 60yrs) heart disease or cardiovasculardisease?

Yes

35. K10 Questionnaire

Please select the answer that is correct for you

a. In the past 4 weeks, about how often did you feel tired out for no good reason?

b. In the past 4 weeks, about how often did you feel nervous?

c. In the past 4 weeks, about how often did you feel so nervous that nothing could calm you down?

d. In the past 4 weeks, about how often did you feel hopeless?

e. In the past 4 weeks, about how often did you feel restless or fidgety?

f. In the past 4 weeks, about how often did you feel so restless you could not sit still?

g. In the past 4 weeks, about how often did you feel depressed?

h. In the past 4 weeks, about how often did you feel that everything was an effort?

i. In the past 4 weeks, about how often did you feel so sad that nothing could cheer you up?

j. In the past 4 weeks, about how often did you feel worthless?

Family History

36. Have you ever been told by a doctor that you have a sleep disorder, sleep apnoea or narcolepsy?

Yes

37. Has anyone told you that your breathing stops or is disrupted by episodes of choking during your sleep?

Yes

38. Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

This refers to your usual way of life in recent times. If you haven’t done some of these things recently try to work out how they would have affected you.

a. Sitting and reading

b. Watching TV

c. Sitting inactive in a public place (e.g. a theatre or a meeting)

d. As a passenger in a car for an hour without a break

e. Lying down to rest in the afternoon when circumstances permit

f. Sitting and talking to someone

g. Sitting quietly after a lunch without alcohol

h. In a car, while stopped for a few minutes in the traffic

39. Audit Questionnaire

a. How often do you have a drink containing alcohol?

b. How many drinks containing alcohol do you have on a typical day when you are drinking?

c. How often do you have six or more drinks on one occasion?(Required)

d. How often during the last year have you found that you were not able to stop drinking once you had started?

e. How often during the last year have you failed to do what was normally expected from you because of drinking?

f. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

g. How often during the last year have you had a feeling of guilt or remorse after drinking?

h. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

i. Have you or someone else been injured as a result of your drinking?

j. Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Section 2 - Declaration and consent

I hereby certify that to the best of my knowledge the answers given above are correct.

I understand that I may be required to remove some clothing (not underwear) and that I am required to provide a urine and/or blood sample, and to undertake a breath test for alcohol.

This is to be signed in the presence of the assessing doctor.

Signature of Examinee(Required)

Date of signature(Required)