Lääkärikeskus Aava Oy/Työterveyshuolto
Työhöntulotarkastuksen esitiedot, englanti

Versio 1.1

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PRELIMINARY INFORMATION FOR PRE-EMPLOYMENT HEALTH EXAMINATION

All given information is considered confidential

PERSONAL DATA
Last name / First names
Identity code / Address
Postal code / City / Office telephone
Home telephone / Mobile / E-mail address
Occupation/task / Marital status
Education / My family includes
adults and child/children
Company name / Conscription completed in
Fitness class
Supervisor
Current job started in
Description of current job
Exposure present in current job(are they, e.g., psychological, chemical, physical, biological)?
Have you had sufficient training for your current work tasks?
Are you given enough time at work to complete your tasks?
PREVIOUS EMPLOYMENT
Employer / Profession / Dates
Employer / Profession / Dates
Employer / Profession / Dates
Employer / Profession / Dates
Employer / Profession / Dates
Employer / Profession / Dates
Employer / Profession / Dates
Did your previous work tasks contain exposures / stress factors (e.g., psychological, chemical, physical, biological) relevant to your health?
Diagnosed occupational disease or work limitation
INFORMATION REGARDING YOUR STATE OF HEALTH
Current health? (On a scale of 0 to 10,Good = 10 Bad= 0)
How would you evaluate your well-being at the moment? (On a scale of 0 to 10,Good = 10, Bad= 0)
HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS OR ILNESSES?
FOR ALL QUESTIONS, SELECT ‘YES’ OR ‘NO’.
Yes / No / Yes / No
Neck/shoulder pains / Obesity
Lower back illness / Diabetes mellitus
Arm or leg pains / Epilepsy
Rheumatoid arthritis / Gallstones
Other musculoskeletal disorder / Disease of the liver or pancreas
Hypertension / Gastric ulcer
Chest pains / Disease of the large intestine
Cardiac insufficiency / Other disease in the digestive organs
Other disease of the cardiovascular system / Urinary tract infection
Prolonged rhinitis / Kidney disease
Recurring respiratory tract infection / Women; ovarian infection
Asthma / Men; prostate disease
Pulmonary emphysema / Disease in the urinary and genital organs
Other respiratory disease / Allergies
Mental disorder / Other eczema
Depression / Other skin disease
Sleep disorder / Benign tumour
Ear disease / Malignant tumour
Eye disease / Goitre or thyroid disease
Migraine / Celiac disease
Anaemia / Lactose intolerance
Other blood disease / Other metabolic disorder
Accident / Congenital defect
Other illness or disorder
Additional information
Medication / Allergies to medicines?
How many days of sick leave did you have last year?
Special diet
Eating habits
I eat regularly, approx. every 4 to 5 hours
Yes No / Half or more of my plate contains vegetables, fruits, or berries?
Yes No
Exercise habits
time/week What exercise?
Smoking / snuff use
Yes No / I have smoked for years cigarettes/day
I quit smoking in
Alcohol use
I use alcohol, number of servings per time:
I do not use alcohol / How often do you use alcohol?
times a day, times a week,
times a months, times a year
Do you use other intoxicants?
Yes; what? No / Teeth: checked in
not checked I use dentures
Vaccinations
Tetanus-diphtheria
Polio
MPR
Other, what? / Year / Vaccinations
Hepatitis A +B
Hepatitis A
Hepatitis B / Year
ONLY FOR WOMEN:
Child-births in Are you pregnant? Yes, due date No
Pap smear in Mammogram in
DISEASES IN THE IMMEDIATE FAMILY:
Cardiovascular diseases
Hypertension
Diabetes mellitus
Asthma
Cancer
Mental disorders
Other diseases / Yes No who?
Yes No who?
Yes No who?
Yes No who?
Yes No who?
Yes No who?
Yes No who?
Previous health examination performed: in, where
I HEREBY CONFIRM THAT THE INFORMATION I HAVE PROVIDED IS TRUTHFUL:
Place and time
Signature of employee