Student Health Questionnaire

"*" indicates required fields

1Consent

2Information

3Physical Health and Functional Capabilities

4Mental Health and Cognitive Capabilities

5Medications

6Hepatitis C and HIV

7Vaccination History

Consent

The questionnaire will take approximately 10 to 20 minutes to complete, and a response to all questions is required. The questions will assess:

Physical Health and Wellbeing
Mental Health and Wellbeing
Immunisations to date
General Health

It is important to answer all questions thoroughly and honestly so that a balanced clinical review can take place. Where applicable, at the end of the questionnaire you will be required to upload a record of the immunisations you have previously had. This can be obtained by contacting your GP.

Please ensure you have your immunisation records to hand prior to completing the questionnaire. You will be required to upload your records prior to submitting your responses. Your records can be obtained by contacting your GP. In rare cases you may need to contact your childhood GP where this differs from your current.

Possible outcomes

Depending on the initial assessment result, you will:

a) Be issued with a certificate to confirm fitness to study and fitness to practice (subject to Immunisations clearance).
b) Be notified that a virtual consultation is required with a member of our clinical team which will be booked as a priority.

We will review your immunisations record(s), and where this has met the requirements, we will let you know. Where you have not previously had immunisations that are required for the role, you will be invited to take part in the immunisations program.

Only approved representatives from Innovate Healthcare will have access to the individual question responses.

Information

Title*

First Name*

Surname*

Student number*

Course title*

University / College*

Date of Birth*

Best contact number*

Email address*

Address*

Address Line 1 Address Line 2 City Postcode Country

Physical Health and Functional Capabilities

Your weight in kgs:*

Your height in feet and inches:*

1. Do you have issues with any of the following?

Mobility*

e.g., walking, using stairs

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Agility*

e.g., bending, reaching up, kneeling down, maintaining balance

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Dexterity*

e.g., writing, using tools

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Physical exertion*

e.g., lifting, carrying

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Within the last 3 years have you suffered from any medical conditions that affect your muscles, ligaments or joints that may impact on your ability to undertake any aspect of the course?*

Please give details*

Do you feel that you require any adjustments in relation to a musculoskeletal concern to allow you to undertake the course?*

Please give details*

Communication*

e.g., speech

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Hearing*

e.g., deaf, hard of hearing, tinnitus

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Visual deficits that you feel would impact on any essential functions of the course?*

e.g., blind, visual impairment, tunnel vision

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Have you been diagnosed as having a colour deficit (colour blind)?*

e.g., blind, visual impairment, tunnel vision

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Skin*

e.g., allergies, skin conditions, eczema, psoriasis, latex allergy

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Upper Limb Function*

e.g., manual handling

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

2. Have you ever been affected by any of the following?

Sudden loss of consciousness*

e.g., a fit or seizure

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Chronic fatigue syndrome (or similar condition)*

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Epilepsy / Blackouts*

Do you suffer from blackouts, epilepsy or any condition that would pose a safety risk to either yourself, other students, or the general public?

Please provide further details*

Do you have any restriction on driving imposed by the DVLA?

Please provide details*

An illness requiring more than two week’s absence from school or work*

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

3. Do you have any chronic lung or heart disorder?*

Please give details*

e.g., when condition developed, severity, treatment

Do you suffer from any respiratory condition, including obstructive sleep apnoea syndrome?*

Please give details*

Do you require any medical support with regard to a respiratory condition?*

Please provide details*

4. Do you have any allergies, including any drug or vaccinations allergies?*

Please give details*

For example, what do you take, what for, side effects

5. Have you been treated with steroids in the past 18 months?*

Please give details*

For example, when condition developed, severity, treatment

6. Do you have any other health problem that reduces your immune system?*

Please give details*

For example, when condition developed, severity, treatment

7. Are you pregnant?*

Please confirm if you are over or under 28 weeks pregnant*

8. From your knowledge of the course that you will be doing, is there anything that you feel may impact on your health or a medical condition?*

Please give details*

For example, when condition developed, severity, treatment

Are you currently receiving any treatment or investigations for any condition?*

Please give details*

For example, when condition developed, severity, treatment

Do you require any adjustments to be made to the course or course environment due to a medical condition?*

Please give details*

For example, when condition developed, severity, treatment

Have you been treated for alcohol related problems or advised to reduce your alcohol intake within the last 24 months?*

Please give details*

For example, when condition developed, severity, treatment

Have you been treated for drug related problems within the last 24 months?*

Please give details*

For example, when condition developed, severity, treatment

Mental Health and Cognitive Capabilities

9. Do you have any issues with any of the following?

General cognition e.g., concentration, awareness, memory.*

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Learning e.g., dyslexia, dyspraxia, dyscalculia.*

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

Literacy and numeracy*

Please give details*

For example, the extent of impairment, any support needs or course adjustments required.

10. Have you ever required special arrangements at school, college or work to overcome any learning barriers?*

Please give details*

For example, equipment, extra time in exams, part-time working

11. Have you ever been assessed or treated by a psychiatrist or psychotherapist?*

Please give details*

For example, when, reason, outcome

12. Have you ever been affected by any of the following?

An anxiety disorder / Stress / Panic attacks Requiring medication or other forms of treatment?*

e.g., Generalised anxiety disorder

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

Post-traumatic stress disorder*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

Depression*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

Phobias*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

Schizophrenia or other primary psychotic disorders*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

A nervous breakdown*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

A personality disorder*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

An over-dose and/or any form of self-harm*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

Drug or alcohol dependency*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

An eating disorder*

e.g., bulimia, anorexia nervosa, compulsive eating

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

Any other mental health issue*

Please give details*

For example, when condition developed, how long it lasted, its effects on you, treatment.

13. Do you have any impairment or health condition affecting your cognitive capability not already mentioned?*

Please give details*

For example, when condition developed, severity, treatment.

14. Have you ever been detained under the Mental Health Act 1983?*

Please give details*

For example, date, reason

Hepatitis C and HIV

HIV

HIV (human immunodeficiency virus) is a virus that damages the cells in your immune system and weakens your ability to fight everyday infections and disease.

AIDS (acquired immune deficiency syndrome) is the name used to describe a number of potentially life-threatening infections and illnesses that happen when your immune system has been severely damaged by the HIV virus.

While AIDS cannot be transmitted from 1 person to another, the HIV virus can. There's currently no cure for HIV, but there are very effective drug treatments that enable most people with the virus to live a long and healthy life. With an early diagnosis and effective treatments, most people with HIV will not develop any AIDS-related illnesses and will live a near-normal lifespan.

The following activities would be considered high risk and could result in contracting the HIV infection:

I am female and my male partner has sex with other men
I have had sex with someone that told me they are HIV positive
I am male and have had unprotected sex with another man
I regularly pay for sex
I am regularly paid for sex
I have had sex with someone from a country with a high prevalence for HIV
I share needles with other people

Opt in to have a blood test for HIV?*

Yes I would like to be tested

Hepatitis C

Hepatitis C is a virus that can infect the liver. If left untreated, it can sometimes cause serious and potentially life-threatening damage to the liver over many years.

But with modern treatments, it's usually possible to cure the infection, and most people with it will have a normal life expectancy.

It's estimated around 215,000 people in the UK have Hepatitis C.

You can become infected with it if you come into contact with the blood of an infected person.

The following activities would be considered high risk of contracting Hepatitis C

If you have received a blood transfusion before September 1991 or a blood product (such as clotting factor) before 1986 in the UK.
If you ever shared a needle or other equipment for injecting drugs, even if it was just once or many years ago.
If you ever had medical or dental treatment abroad in unsterile conditions.
If you ever had a tattoo, piercing, acupuncture, electrolysis or semi-permanent make-up using equipment that may have been unsterilised.
If you have ever had unprotected sex with someone who has or might have had Hepatitis C, particularly if there were opportunities for blood-to-blood contact during sex.
If you have ever shared a razor or toothbrush with someone who has, or might have, Hepatitis C

Opt in to have a blood test for HEP C?*

Yes I would like to be tested

Vaccination History

Any vaccine-preventable disease that is transmissible from person to person poses a risk to both healthcare professionals and their patients. Healthcare workers have a duty of care towards their patients which includes taking reasonable precautions to protect them from communicable diseases. Immunisation of healthcare and laboratory workers may therefore:

Protect the individual and their family from an occupationally-acquired infection
Protect patients and service users, including vulnerable patients who may not respond well to their own immunisation
Protect other healthcare and laboratory staff
Allow for the efficient running of services without disruption.

The Government has clear guidelines for vaccination and immunisation of Health Care Workers within the UK. The guidance ‘Greenbook Chapter 12’ can be viewed here.

Routine vaccinations and those required for direct patient care:

Please select how many dose of a vaccination you have had and 'No' where you have none, for each vaccination. You will need to upload the appropriate evidence at the bottom of the page using the upload attachments section. Remember for HepB this also includes the serology report (blood test result).

Vaccine: Hepatitis B*

Vaccine: MMR*

Vaccine: BCG (TB) or do you have a BCG scar?*

Would you like an Influenza vaccine this year?*

Vaccine: Polio*

(Often given as combined vaccination named DPT, 3 In 1 or 3N1)

Vaccine: Varicella*

Have you had Chicken Pox or Varicella Vaccine?*

Commonly acquired in childhood, if unsure check with a parent or guardian.

Please upload evidence of all Vaccinations and Immunisations

Drop files here or

Accepted file types: jpg, png, heic, pdf, docs, docx, doc, Max. file size: 8 MB.

Multiple files is allowed.

Untitled

Student Health Questionnaire

Consent

Possible outcomes

Information

Physical Health and Functional Capabilities

Mental Health and Cognitive Capabilities

15. Medications

Hepatitis C and HIV

HIV

Hepatitis C

Vaccination History

Routine vaccinations and those required for direct patient care: