HAVS & Medical Questionnaire - Quantum Construction & Rail Services

The below questions form part of 2 separate questionnaires, this is why there may be some repetition. Please answer all questions thoroughly.

HAVS Declaration (RF/27)

Confidential Assessment of Hand-Arm Vibration

HAVS & Medical RF/27 - Please type 'x' in this box*

Your name*

E-mail: (please check your email address is correct)*

Date*

Your address*

Your date of birth*

Your doctors surgery*

1. Hand Symptoms

1a. Blanching. Have you ever suffered from one or more fingers, or parts of fingers, going white on exposure to cold, or following work with vibrating equipment or tools? (YES/NO)*

1b. How many fingers are affected? (0 to 10)*

1c. Which hand(s)? (LEFT/RIGHT/NONE)*

2. Numbness / Tingling (excluding transient tingling after using vibrating tools)
__________________________________________________

2a. Do you have numbness / tingling of the fingers? (YES/NO)*

2b. ...While working? (YES/NO)*

2c. ... In response to the cold? (YES/NO)*

2d. ... With blanching? (YES/NO)*

2e. ... At other times? (YES/NO)*

3. Other

3a. Are you experencing any other problems with muscles or joints of your hands or arms? (YES/NO)?*

3b. If yes, is it pain / swelling / stiffness / weakness, or other? (please state which)

End of the HAVS form. Please type your name below to confirm you agree the above is correct. Then move on to the medical questionnaire. *

Medical Questionnaire (RF/08)

Medical Questionnaire (RF/08) - Please type 'x' in this box*

Your name: *

It is important to be accurate with your answers to this questionnaire. When you declare NO, you are accepting a degree of responsibility for your own safety.

1. Do you have diabetes needing insulin? (YES/NO)*

2. Do you suffer from epilepsy or fits? (YES/NO)*

3. Have you ever suffered blackouts, recurrent dizziness, or any condition which may cause sudden collapse or incapacity? (YES/NO)*

4. Do you get discomfort or pain in the chest, or shortness of breath on excercise (e.g. climbing a single flight of stairs)? (YES/NO)*

5. Do you have high/low blood pressure? (YES/NO)*

6. Are you taking any medication that is causing you dizziness or drowsiness? (YES/NO)*

7. Are you taking any regular medication? (YES/No) If so, please give details at the next question.*

7a. Please give details of any regular medication here.

8. Do you have any problems with height? (YES/NO)*

9. Are you capable or repetative lifting as required for the emplyment? (YES/NO)*

10. Do you have any difficulty with your eyesight (other than the wearing of glasses or contact lenses where required) e.g Colour blindness (YES/NO)*

11. Have you ever had heart problems? (YES/NO)*

12. Have you ever had a serious accident or operation? (YES/NO)*

12a. Please give the details of any serious accident or operation?

13. Do you have any difficulty hearing normal conversation? (YES/NO)*

14. Do you have any back/neck problems? (YES/NO)*

14a. Please give details of any back/neck problems.

16. Have you had a hernia? (YES/NO)*

17. Have you had an illness related to alcohol during the last 12 months? (YES/NO)*

18. Have you used any drug of abuse (not alcohol or tobacco) within the last 12 months? (YES/NO)*

End of Medical Questionnaire.

Please type your name below to confirm you agree the above information is correct? *

Todays date*

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