Cape York Medical Questionnaire

The purpose of this form is to indicate if you have any medical condition which may be aggravated by the activities you will be participating in during your Cape York secondment. The information may be helpful in determining any assistance that can be provided to you to ensure your health and safety whilst in the Cape.

The personal information that you provide on this form is protected by privacy laws. Access to this information is available to yourself and the Project Manager and is confidential. An Occupational Rehabilitation Consultant within your companymay be consulted regarding a medical condition, and if required, further information from your treating medical practitioner requested. Any information collected or disclosed to us will only be used for the purposes of determining the effect of any illness or injury on your ability to perform your work duties whilst on secondment.

If you have a medical condition that you think may preclude you from participating in a Cape York secondment, please discuss this with the Project Manager, as in many circumstances, your medical condition can be accommodated, whether by additional equipment or placement in a secondment closer to medical assistance.

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Questions:

  1. Will you be required to take any regular serious medication during your stay in Cape York? Yes / No

Details______

  1. Do youhave, or haveyou had, any pre-existing medical condition that might impact on your ability to undertake the activities included in the Cape York program? Yes / No

Condition / x if applicable / Condition / x if applicable
Back or neck pain / surgery / Anxiety / Depression
Heart condition / Post traumatic Stress Disorder
Asthma / Counselling for an emotional or psychological consideration or traumatic event
Diabetes / Physical disability
High blood pressure / Skin condition (such as dermatitis, eczema etc)
Epilepsy / Other medical condition

If yes to any of the above, please advise date of injury / preventative strategies & management requirements:______

______

Are you pregnant? Yes / No

______

  1. Do you have any allergies to the following:

Allergy / Yes / No / Allergy / Yes / No
Medications / Pollen or flower products
Animals / Environmental
Bee Stings / Foods
Other insects / Other

Please give details of any condition and please advise the seriousness of your allergy by rating;

Minor- causes some discomfort but easily controlled by over the counter drugs

Moderate- causes considerable discomfort and requires prescription drugs

Serious- potentially life threatening without urgent medical intervention

______

______

  1. Do you require any medications to be refrigerated? Yes / No

If yes, please give details: ______

  1. Do you require any particular foods for medical purposes? Yes / No

If yes, please give details: ______

Please also advise if you have special dietary restrictions (eg. Vegetarian, Gluten, Lactose etc)

  1. Do you have any other health / welfare considerations you think may be relevant regarding a secondment in Cape York? Yes / No

Please advise: ______

______

  1. If you are concerned, it is recommended that you consult with your regular medical practitioner or specialist Travel Doctor regarding the following vaccinations:
  2. Diptheria/Tetanus/Pertussis
  3. Measles/Mumps/Rubella
  4. Influenza (recommended annual vaccination)
  5. Hepatitis A
  6. Hepatitis B

Any associated costs are to be borne by you.

Please also note that there can be Dengue Fever outbreaks in Far North Queensland. For more information on Dengue outbreaks and reducing the risk of infection, please visit the Queensland Government Dengue site

Please complete, insert name and date and return via email to:

  • Jackie Curran no matter what company you are from
  • Please also email to Vit Koci,if you are from WESTPAC

The information provided by me on this form is correct, to the best of my knowledge.

Full Name: ______

Signed:______

(please physically sign then scan and email this form)

Dated: ___/___/_____

If you have any questions or queries about this form, please contact Jackie Curranor Vit Koci and/or your companyWH&S representative.

WH&S

Please note that whilst you are on secondment, as you are still paid by your main employer, you will be covered by their relevant WH&S policies. Please familiarise yourself with your organisation’s WH&S policies and refer any questions to your company contact or HR department