Wellbeing Medical Form

Wellbeing Occupational Health

(Please select or fill in the appropriate answer (incorrect or dishonest information will invalidate this medical)

1. Medical History (Any medical or surgical problems past or present)

A) Did you fail a medical check before?

2. Can you work at heights?

A) Do you feel dizzy or weak?

B) No epilepsy or medical problem, hearing problems?

3. Medication in Use (Are you using any medication?)

A) Dagga or drugs in use?

4. Problems with noise, dust, sun, or walking up the stairs (getting tired)

5. Female patients are required to test for pregnancy on their own responsibility or notify the examiner if there are any signs or symptoms. Any signs or symptoms

The test strips used in this test do not check for pregnancy. It is the client’s responsibility to check or to notify the examiner if there are any signs or symptoms, which will guide the examiner to request a pregnancy test.

6. Any spectacles, eye problems, or restriction on license?

7. Any fainting before?

8. Stabbing, gunshot, car accidents?

10. I am exposed to chemicals

11. I am exposed to heat stress

12. I declare that I am not ill or do not have a medical problem

13. Audiometric Testing, Do you have a problem with hearing, any itchiness, or accidents to your ears before?

14. I do have a medical complaint or problem (Please disclose in the block below. Please note to fill in below for any medical issues, including any hearing problems, any itchiness, or accidents to your ears before.)

Disclaimer

N.B. If I don’t disclose my issues or challenges, the examiner will not know of my complaints.

Wellbeing Medical hereby follows the POPI Act Regulations. This site is locked from all users except the professional healthcare examiner.

I hereby agree to disclose my medical information, as it is a requirement in order to complete this medical examination.

Incorrect information provided will affect the focus of the examination, and the examiner is not responsible for incorrect information.

The patient has to answer all the questions on their own. An interpreter will be made available. The patient has the right to refuse or continue with this examination.

Name of Employee

I hereby declare that the information provided is true and honest. If the information provided is incorrect, the examination will not be accurate.

Print Name

Wellbeing Occupational Health

Disclaimer

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