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Health Status Questionnaire Form Q1

This document is a health questionnaire for an employee. It collects information about the employee's current and past medical conditions, treatments, and health behaviors. The questionnaire addresses conditions like high blood pressure, heart disease, injuries, mental health, substance use, and traffic incidents. It collects details to identify any health issues that may impact the employee's job duties or safety. The employee signs to confirm the accuracy of the provided information, which a health advisor will then review and note any comments.

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Kathleen Chua
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366 views2 pages

Health Status Questionnaire Form Q1

This document is a health questionnaire for an employee. It collects information about the employee's current and past medical conditions, treatments, and health behaviors. The questionnaire addresses conditions like high blood pressure, heart disease, injuries, mental health, substance use, and traffic incidents. It collects details to identify any health issues that may impact the employee's job duties or safety. The employee signs to confirm the accuracy of the provided information, which a health advisor will then review and note any comments.

Uploaded by

Kathleen Chua
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Shell Health Appendix D Form Q1

Health Status Questionnaire

Please answer the questions by ticking the correct box. If you are not sure, leave the question
blank and ask your health advisor what it means. Your health advisor may ask you additional
questions during the examination.

Employee Data Date

Last Name First Name

I.D No. Tel # Occupation


No Yes
1. Are you currently being treated by a doctor for any illness or injury?  
If yes please briefly describe

2. Are you receiving any medical treatment or taking any medication (either prescribed or  
otherwise)?

If yes please list

3. Have you ever had, or been told by a doctor that you had any of the following? No Yes
3.1 High blood pressure  
3.2 Heart disease  
3.3 Chest pain, angina  
3.4 Any condition requiring heart surgery  
3.5 Palpitations/irregular heartbeat  
3.6 Abnormal shortness of breath  
3.7 Head injury, spinal injury  
3.8 Seizures, fits, convulsions, epilepsy  
3.9 Blackouts, fainting  
3.10 Stroke  
3.11 Dizziness, vertigo, problems with balance  
3.12 Double vision, difficulty seeing  
3.13 Colour blindness  
3.14 Kidney disease  
3.15 Diabetes  
3.16 Neck, back or limb disorders  
3.17 Hearing loss or deafness or had an ear operation or use a hearing aid  
3.18 Do you have difficulty hearing people on the telephone (including use of hearing aid if  
worn)?
Form Q1 Continued

3.19 Have you ever had, or been told by a doctor that you had a psychiatric illness, or nervous  
disorder?
3.20 Have you ever had any other serious injury, illness, operation, or been in hospital for any  
reason?
4.1 Have you ever had, or been told by a doctor that you had a sleep disorder, sleep apnoea, or  
narcolepsy?
4.2 Has anyone noticed that your breathing stops or is disrupted by episodes of choking during  
your sleep?
5.1 When was the last time you had more than 4 drinks (female) or 5 drinks (male) in 1 day in the past 3 months
 last 7 dayslast 4 weeks  last 3 months  not in the last 3 months
5.2 Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested
you cut down?
No Yes, but not in the last year Yes, during the last year
No Yes
6. Do you use illicit drugs? 
6.1 Have you ever been treated for alcohol or substance abuse
 
7. Do you smoke? If yes, what and how much each day?  
8. Do you use any drugs or medications not prescribed for you by a doctor?  
If yes list here.

9. Have you been in a vehicle crash since your last license examination? ( Drivers only)  
If Yes, please give details:

Declaration: I, (Print Name) certify that to the best of my


knowledge the above information supplied by me is true and correct.

Signature: Date:
Office use only
Health advisor’s comments

Date Signature Print Name

Acknowledgement: Adapted from Australian Driving Standards

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