THIS INFORMATION IS CONFIDENTIAL TO WORKING WELL

Working Well, The Orchard Centre, Gloucestershire Royal Hospital, Gloucester, GL1 3NN T: 01452 894480, E:

Fitness to Work at Heights Assessment Form
(Not Climbers/Riggers) / Issue 2: Nov 2015
WWF-033

PERSONAL DETAILS:

Surname:. / First Name:
Site: . / Job:
Date of Birth: . / OPAS PIN No.

Medical History:

1 / Have you ever experienced a Fear of Heights, Panic attacks, Vertigo or other phobias? / YES / NO
2 / Have you ever experienced or do you suffer from; Fainting attacks, Frequent falls, MS, Menieres Disease, Dizziness, Dyspraxia or problems with your co-ordination or balance? / YES / NO
3 / Do you have any history of altered consciousness in the last 12 months? (E.g. Epilepsy, Transient Ischemic Attacks (Mini Stroke), Head Injury, Diabetic ‘Hypo’ etc) / YES / NO
4 / Do you now, or have you ever had chest pain, heart arrhythmias / heart problems, high blood pressure, Angina or a heart attack? / YES / NO
5 / Have you ever been diagnosed with diabetes? / YES / NO
6 / Do you take any medicines – prescribed, over the counter, homeopathic or other - either regularly or as required? / YES / NO
7 / Do you suffer from Asthma / Chronic Obstructive Pulmonary Disease or any other breathing problems? / YES / NO
8 / Do you have any problems with your back, neck, knees, feet, joints or have any difficulty moving freely (e.g. injury or arthritis) or accessing your work space ? / YES / NO
9 / Have you ever had any mental health problems, self harmed / attempted suicide or taken medicines for anxiety or depression? / YES / NO
10 / Have you been admitted to hospital / required hospital investigation or treatment in the last 12 months – or are you waiting for GP or other investigations / treatment? / YES / NO
11 / Do you have any problems with your Vision / Speech / Hearing? / YES / NO
12 / Have you every taken illicit drugs, or been treated for drug or alcohol problems? / YES / NO
13 / Have you ever suffered episodes of sudden Pain (Abdominal / Irritable Bowel Syndrome / Angina / Migraine)? / YES / NO
14 / Have you ever suffered any condition affecting your understanding (E.g. dementia, brain damage) or your ability to assess risks (E.g. Poor perception, mental handicap)? / YES / NO
15 / Do you have any medical condition or other problem that could be made worse by wearing a fall arrest harness or other PPE (e.g. Inguinal Hernia, Recent Operation)? / YES / NO
16 / Do you consider yourself to have a disability or any other reason that you might not be fit to work at a height? / YES / NO

Please give details for any positive ‘YES’ below:

Additional Information
Declaration
I hereby declare that all the medical information given by me is true and accurate to the best of my knowledge and I have not omitted anything which might have a bearing on the outcome of this examination. I undertake to advise my manager of any change to my health which may impact on my ability to Work-at-Height, and will refrain from such work until further advice has been sought.
Signature of employee ______Date ______/______

Health Assessment FIT

1 – Distance Vision: Both 6 / ...... Left 6 / ...... Right 6 / ...... Y/N

2 – Hearing: Whisper Test Pass Y / N Audiology Required Y / N Y/N

3 – Cardio: BP ...... / ...... mm/Hg Pulse ...... bpm Reg Y / N Y/N

4 – Lung Function: Normal Spiro Y / N Within 75 % Y / N Y/N

5 – Locomotion: PMVA Standard Y / N Romberg’s Y / N Y/N

6 – Urinalysis: Glucose Y / N Y/N

7 – Mental Health: Mental Health Issues of Concern Y / N Y/N

8 – Medication: Any Contradicted Effects / Side Effects Y / N Y/N

9 – Drug & Alcohol: Recent / Current D & A Problems Y / N Y/N

Clinical Notes:
______
Clinical Assessment Outcome
Fit □ Fit with Rec’s □ Temporarily Unfit □ Not Fit □ Referred For further Opinion □
Examination carried out by: ______
Examiner’s Signature: ______Date ______/______/______
OH Advisor (Name / Designation): ______Review Date ______/______/______