Oil and Gas – Offshore Medical Screening Questionnaire

Title*

Surname*

First Name*

Middle Name

Date Of Birth*

Telephone Number*

Offshore occupation/Job title*

Emergency response role

Date of last offshore medical*

Address 1*

Address 2

City*

Postcode*

Name of GP

NHS No. (CHI NO.)

Surgery Name*

Surgery Phone*

Do you smoke? If so, how many per day?*
YesNo

Have you ever been exposed to any known occupational hazard such as noise, radiation, dusts, asbestos, chemicals or lead?*
YesNo

Do you use protective clothing, safety glasses or hearing protection?*
YesNo

Have you ever developed any medical condition in connection with your occupation? If so, please give details e.g., hearing loss/skin condition/ wheeze/ backache/ muscle strain/ blood disease?*
YesNo

Have you ever suffered any industrial injury? If so, please give details*
YesNo

Have you ever had any previous audiometric screening? Was this normal? State when and where*
YesNo

Have you ever had previous lung function screening? Was this normal? State when and where*
YesNo

Have you ever been rejected from employment on medical grounds?*
YesNo

Have you ever received compensation or is there any industrial claim pending?*
YesNo

Have you ever been medivaced from an offshore installation?*
YesNo

Backache/joint or muscular pain*
YesNo

High Blood pressure / stroke*
YesNo

Asthma / epilepsy / diabetes*
YesNo

Peptic ulcer disease*
YesNo

Kidney disease (eg stones)*
YesNo

Psychiatric disorder (eg anxiety/depression)*
YesNo

Tuberculosis*
YesNo

Cancer*
YesNo

Backache/joint or muscular pain*
YesNo

Hernia / rupture*
YesNo

Visual impairment*
YesNo

Perforated eardrum / discharge form ear*
YesNo

Recurrent indigestion*
YesNo

Jaundice / hepatitis / gall bladder disease*
YesNo

Change in bowel habit/diarrhoea*
YesNo

Blood in stools/piles/haemorrhoids*
YesNo

Shortness of breath/coughing up blood*
YesNo

Recurrent bronchitis/ pneumonia*
YesNo

Blood in urine/ kidney complications/ stones*
YesNo

Headaches/ migraine/ dizziness*
YesNo

I certify the above information is correct:*

Date:*