| | | |
| * Any illness or disorders whilst working nights? |
Yes
No
|
| If Yes, please give details |
|
| * Epilepsy / Blackouts / Fainting? |
Yes
No
|
| If Yes, please give details |
|
| * Angina? |
Yes
No
|
| If Yes, please give details |
|
| * High Blood Pressure? |
Yes
No
|
| If Yes, please give details |
|
| * Heart Disease? |
Yes
No
|
| If Yes, please give details |
|
| * Chest Pains / Palpitations? |
Yes
No
|
| If Yes, please give details |
|
| * Asthma? |
Yes
No
|
| If Yes, please give details |
|
| * Diabetes? |
Yes
No
|
| If Yes, please give details |
|
| * Ulcers? |
Yes
No
|
| If Yes, please give details |
|
| * Back Pain? |
Yes
No
|
| If Yes, please give details |
|
| * Hernias / Rupture? |
Yes
No
|
| If Yes, please give details |
|
| * Rhuematism / Arthiritis / Gout? |
Yes
No
|
| If Yes, please give details |
|
| * Psychiatric Illness? |
Yes
No
|
| If Yes, please give details |
|
| * Eye Disease / Poor Eye Sight? |
Yes
No
|
| If Yes, please give details |
|
| * Ear Disease / Deafness? |
Yes
No
|
| If Yes, please give details |
|
| * Eczema / Dermatitis? |
Yes
No
|
| If Yes, please give details |
|
| * Migraines / Frequent Headaches? |
Yes
No
|
| If Yes, please give details |
|
| * Vibration White Finger? |
Yes
No
|
| If Yes, please give details |
|
| * Repetitive Strain Injury? |
Yes
No
|
| If Yes, please give details |
|
