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(03) 9576 7000
Medical Declaration Update
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Educator
(Required)
First Name
Last Name
Phone
(Required)
Email
(Required)
Medical Declaration
Do you, or have you ever had:
Allergies, including to drugs; animals; bee stings; pollens; grass; food; rubber; chemicals
(Required)
Yes
No
Please provide additional information
(Required)
Heart Conditions, including heart attacks; high/low blood pressure; murmur; palpitations; ect
(Required)
Yes
No
Please provide additional information
(Required)
Stroke, including Clots in the Legs or Lungs; Excessive Bleeding or Bruising; DVT; Varicose Veins
(Required)
Yes
No
Please provide additional information
(Required)
Nervous System Disorders, including Paralysis; Blackouts; Dizzy Spells; Fainting; Epilepsy; Muscular Weakness; Numbness; Coordination Problems
(Required)
Yes
No
Please provide additional information
(Required)
Eye Conditions, Restricted Vision; Glaucoma Iritis; Colour Blindness; ect
(Required)
Yes
No
Please provide additional information
(Required)
Ear Conditions, including Restricted Hearing; Tinnitus; Ear Infections; Hearing Loss; Hearing Difficulties
(Required)
Yes
No
Please provide additional information
(Required)
Skin Conditions, including Eczema; Dermatitis; Rash; Psoriasis; Recent Skin Infection; Skin Cancer
(Required)
Yes
No
Please provide additional information
(Required)
Lung Conditions, including Asthma; Bronchitis; Pleurisy; Tuberculosis; Coughing Blood; Chest Complains; Silicosis; Asbestosis
(Required)
Yes
No
Please provide additional information
(Required)
Digestive System Conditions, including Colitis; Gastric Ulercs; IBS; Hepatitis; Liver Complaints; Pancreatitis
(Required)
Yes
No
Please provide additional information
(Required)
Migraine, including Persistent Headaches; Head Injury
(Required)
Yes
No
Please provide additional information
(Required)
Sleep Disorders, including Issues with Sleep; Excessive Fatigue
(Required)
Yes
No
Please provide additional information
(Required)
Chronic Fatigue, lasting greater than 6 weeks
(Required)
Yes
No
Please provide additional information
(Required)
Take medication to help you sleep or remain alert or awake?
(Required)
Yes
No
Please provide additional information
(Required)
Rheumatic Fever
(Required)
Yes
No
Please provide additional information
(Required)
Kidney/ Bladder Conditions, including Kidney Stones; Urinary Infection; Prostate Problems
(Required)
Yes
No
Please provide additional information
(Required)
Arthritis, Gout, Join Pain or Swelling
(Required)
Yes
No
Please provide additional information
(Required)
Feet Problems, including Ankle Problems; Foot Pain; ect
(Required)
Yes
No
Please provide additional information
(Required)
Knee Injury, Swelling or Pain
(Required)
Yes
No
Please provide additional information
(Required)
Shoulder Pain, Tendonitis, or Frozen Shoulder
(Required)
Yes
No
Please provide additional information
(Required)
Back/ Neck Problems, including Disc Problems; Prolonged Pain; Sciatica, ect
(Required)
Yes
No
Please provide additional information
(Required)
Broken Bones or Fractures
(Required)
Yes
No
Please provide additional information
(Required)
Repetitive Strain Injury, including Tendonitis; Tennis Elbow; Carpal Tunnel; ect
(Required)
Yes
No
Please provide additional information
(Required)
History of Tropical / Infectious Diseases, including Malaria; Hepatitis; Tuberculosis; Dengue Fever
(Required)
Yes
No
Please provide additional information
(Required)
Diabetes or Thyroid Problem
(Required)
Yes
No
Please provide additional information
(Required)
Cancer or Other Tumors
(Required)
Yes
No
Please provide additional information
(Required)
Mental Illness / Stress including, Nervous Breakdowns; Mental Fatigue; Depression; ect
(Required)
Yes
No
Please provide additional information
(Required)
A pace maker or any other implantable device
(Required)
Yes
No
Please provide additional information
(Required)
Are you receiving medical treatment at the present time than an employer should know about?
(Required)
Yes
No
Please provide additional information
(Required)
Do you currently have any work restrictions certified by a Doctor?
(Required)
Yes
No
Please provide additional information
(Required)
Do you take medication for any of the above ticked medical conditions?
(Required)
Yes
No
Please provide additional information
(Required)
Other Existing Medical Conditions
(Required)
Existing is a medical condition for which treatment is still being received.
Yes
No
Please provide additional information
(Required)
Hold a conditional Drivers License
(Required)
With restrictions due to medical conditions, or a condition you have reported to a licensing authority
Yes
No
Please provide additional information
(Required)
Work Related Health History
Other Pre-existing Medical Conditions
(Required)
Pre-existing is where an injury or medical condition(s) is present, but treatment is not required.
Yes
No
Please provide additional information
(Required)
Have you ever experienced conflict or stress at work that required medical treatment or counselling?
(Required)
Yes
No
Please provide additional information
(Required)
Have you ever left, or been denied a job on health grounds?
(Required)
Yes
No
Please provide additional information
(Required)
Have you ever been advised for medical reasons, not to do night work, shift work, or any other kind of work?
(Required)
Yes
No
Please provide additional information
(Required)
Have you ever lodged a Workers Compensation Claim?
(Required)
Yes
No
This field is hidden when viewing the form
Please provide additional information
(Required)
Have you ever had a Worker's Compensation Claim?
(Required)
Yes
No
Please provide additional information
(Required)
Vaccination History - Have you had the following?
Had Chicken Pox?
(Required)
Yes
No
Had Mumps?
(Required)
Yes
No
Had Measles?
(Required)
Yes
No
Had Whooping Cough?
(Required)
Yes
No
Had Covid-19?
(Required)
Yes
No
Had Hep A?
(Required)
Yes
No
Had Hep B?
(Required)
Yes
No
Had Flu Shot?
(Required)
Yes
No
Social History
Do you currently smoke?
(Required)
Yes
No
Please provide additional information
(Required)
Extra Details - Do you have difficulties with the following activites?
Kneeling or Crouching?
(Required)
Yes
No
Please provide additional information
(Required)
Climbing Stairs or Ladders?
(Required)
Yes
No
Please provide additional information
(Required)
Repetitive Movement of Hands or Arms?
(Required)
Yes
No
Please provide additional information
(Required)
Working in extremes of temperature?
(Required)
Yes
No
Please provide additional information
(Required)
Concentrating on a Task?
(Required)
Yes
No
Please provide additional information
(Required)
Reading ordinary print?
(Required)
Yes
No
Please provide additional information
(Required)
Hearing a normal conversation?
(Required)
Yes
No
Please provide additional information
(Required)
Walking on Rough or Uneven Ground?
(Required)
Yes
No
Please provide additional information
(Required)
Standing or Sitting for 2 hours or more?
(Required)
Yes
No
Please provide additional information
(Required)
Lifting or Bending?
(Required)
Yes
No
Please provide additional information
(Required)
Gripping Firmly with Both Hands?
(Required)
Yes
No
Please provide additional information
(Required)
Confined Spaces?
(Required)
Yes
No
Please provide additional information
(Required)
Shift Work?
(Required)
Yes
No
Please provide additional information
(Required)
Turning your Head Rapidly?
(Required)
Yes
No
Please provide additional information
(Required)
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?
(Required)
Yes
No
Please provide additional information
(Required)
Fatigue Assessment
Have you worked in a previous role that requires at least 10 hours of concentrated effort without a break?
(Required)
Yes
No
Please provide additional information
(Required)
I hereby certify that to the best of my knowledge and belief, the answers provided by me are true and correct
(Required)
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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