Education Health Questionnaire

Step 1 of 3

Please answer all the following questions. If you answer yes, please give details of the condition including dates from onset and date of recovery (if appropriate), stating the name and address of the specialist seen. Continue on a separate piece of paper if necessary and enclose it with your questionnaire.

Have you ever had any illness, medical problem or disability that may currently affect your ability to work safely as a teacher?(Required)

Please give details(Required)

Have you ever been treated in hospital? If yes, please give reason(s) and dates(Required)

Please give details(Required)

Have you ever been medically retired from any job or left any job because of ill health?(Required)

Please give details(Required)

Are you have any current medical treatment or do you have any operations or investigations planned?(Required)

Please give details(Required)

Have you been away from work or study because of ill health during the last two years?(Required)

Please give details(Required)

Have you ever had an operation or serious illnes? For example heart condition or cardiac issues?(Required)

Please give details(Required)

Have you been seen or treated by a doctor or other health professional in the past two years?(Required)

Please give details(Required)

Have you any reason to think you may have reduced immunity due to medication or a medical condition including HIV?(Required)

Please give details(Required)

Do you have diabetes?(Required)

Please give details(Required)

Have you ever had any dizzy spells, epilepsy, fits or blackouts?(Required)

Please give details(Required)

Have you ever had back problems (including the neck)?(Required)

Please give details(Required)

Do you have arthritis, joint or limb problems? Do you have any difficulties bending, lifting or with any other movements?(Required)

Please give details(Required)

Have you ever seen a doctor or health professionals for anxiety, depression or any other psychiatric or psychological problem, including anxiety, nervous debility, nervous breakdown, schizophrenia or eating disorder?(Required)

Please give details(Required)

Have you ever had any problems related to alcohol or drug misuse?(Required)

Please give details(Required)

Do you have hearing loss or other ear problems?(Required)

Please give details(Required)

Do you have any eyesight problems? (Which is not corrected by glasses or contact lenses)(Required)

Please give details(Required)

Are you colour blind?(Required)

Please give details(Required)

Do you have dyslexia?(Required)

Please give details(Required)

Do you have any allergies?(Required)

Please give details(Required)

Do you have hay fever, asthma, bronchitis or other chest conditions?(Required)

Please give details(Required)

In the last 12 months have you ever had any of the following:

A cough which lasted for more than 3 weeks?(Required)

Please give details(Required)

Unexplained weight loss?(Required)

Please give details(Required)

Unexplained fever?(Required)

Please give details(Required)

Coughed up blood?(Required)

Please give details(Required)

Have you ever had tuberculosis (TB) or been in recent contact with open TB?(Required)

Please give details(Required)

Have you ever had, or do you currently have a skin problem? If so, which part of the body was/is affected?(Required)

Please give details(Required)

Have you ever had hepatitis or jaundice?(Required)

Please give details(Required)

Do you have frequent diarrhoea or other bowel disorders?(Required)

Please give details(Required)

Are you taking any pills (other than the contraceptive pill), tablets or medicines at present?(Required)

Please give details(Required)

Have you ever had a health problem caused by your work?(Required)

Please give details(Required)

What is your weight?(Required)

Please give details(Required)

What is your height?(Required)

Please give details(Required)

Do you feel well at present?(Required)

Please give details(Required)

Have you ever tested positive to any of the following:

HIV Antibodies(Required)

Please give details(Required)

Hepatitis B surface antigen(Required)

Please give details(Required)

Hepatitis B Core antibodies(Required)

Please give details(Required)

Hepatitis C antibodies(Required)

Please give details(Required)

Have you lived outside of the UK, in any country for more than three months in the last 5 years?(Required)

Please give details(Required)

Have you ever had a clinical diagnosis of Tuberculosis including management of and measures for its prevention and control?(Required)

Please give details(Required)

Disability Declaration

We comply with the Equality Act 2010 and it’s code of conduct. If you consider yourself to have a disability or to be part of a minority group that may impact your studies please state this. We can help assess and advise on what adjustments or assistance may be needed to assist you with completing your studies or work placement.

Do you consider yourself to have a disability?(Required)

Please give details(Required)

By pressing submit you are declaring that all the information you have provided is true to the best of your knowledge(Required)

Submit

Name(Required)

Title First Last

Student Number(Required)

Course Title(Required)

University/College(Required)

Date of birth(Required)

Best contact number(Required)

Email address(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature(Required)

Date(Required)