iii
Have you ever ceased any sports or recreation due to injury or illness?
Yes
No
If yes, please provide details
Medical Self Assessment
Instructions: Please read each question carefully and answer yes or no. If you are unsure please answer yes. You will have an opportunity to discuss this further
with the doctor at the time of the assessment.
If your condition is insignificant this will be noted by the doctor at the time of your assessment.
Please note that you must declare medical conditions that occured in the past even if you have fully recovered from the condition.
Do you currently have, or have you ever had:
Respiratory problems
Asthma (incl. childhood asthma)
Yes
No
Exercise induced asthma
Yes
No
Other lung disease (e.g. Tuberculosis,
Yes
No
Sleep Apnoea
Yes
No
Recurrent hay fever or eczema
Yes
No
Recurrent wheezing or shortness of breath
Yes
No
Recurrent cough at night
Yes
No
Orthopaedic injuries or problems
Any back or injury to your back or neck?
Yes
No
Any pain or injury including sprain or fracture to your upper limbs including shoulders, elbows, wrists or hands?
Yes
No
Any operations to lowers limbs, upper limbs or back?
Yes
No
Any other injuries to muscle, ligament, joint or tendon?
Yes
No
Do you ever wear or have you been advised to wear othotics or special footwear?
Yes
No
Neurological
Epilepsy or Seizures
Yes
No
Serious head injury
Yes
No
Head or neck surgery
Yes
No
Stroke
Yes
No
Dizziness/vertigo/problems with balance
Yes
No
Double vision
Yes
No
Migrane or other frequent headaches
Yes
No
Blackouts, fainting/loss or consciousness
Yes
No
Psychiatric or psychological problems
Anxiety
Yes
No
Depression
Yes
No
Post traumatic stress disorder
Yes
No
Self harm
Yes
No
Attempted suicide
Yes
No
Stress
Yes
No
Excessive use of alchol or illicit drugs
Yes
No
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)
Yes
No
Obsessive compulsive disorder
Yes
No
Any visits to a psychologist, councellor or psychiatric for any reason
Yes
No
Any admissions to hospital for psychiatrist for psychological problems
Yes
No
Any other psychological, psychiatric or emotional episodes or disorders
Yes
No
Any use of antidepressant, antianxiety or other psychiatric medication
Yes
No
Cardiovascular
Palpitations or irregular heart beats
Yes
No
Heart murmur
Yes
No
Chest pain on exerton or angina
Yes
No
Abnormal shortness or breath
Yes
No
Heart attack
Yes
No
Any other heart disease
Yes
No
Cardiac surgery or procedure (e.g. angiogram)
Yes
No
High blood pressure
Yes
No
Smoked cigarettes
Yes
No
High cholesterol
Yes
No
A family history of heart disease
Yes
No
Applicants 35 or older will require resting ECG
Applicants 40 or older will require a stress ECG
Applicants 45 or older, or those with multiple risk factors will require a full cardiac risk assessment
These tests are at the applicant's expense
Endocrine
Pre-Diabetes
Yes
No
Type 1 Diabetes
Yes
No
Type 2 Diabetes
Yes
No
Thyroid condition
Yes
No
Any other endocrine disorder
Yes
No
Vision
Do you wear glasses or contact lenses?
Yes
No
If yes, for what purpose?
Have you had corneal surgery (photofractive/lasik)
Yes
No
Have you had surgery with an implanted lense?
Yes
No
Have you had problems with colour vision?
Yes
No
Have you had trouble with your vision in any way throughout your life e.g. childhood squint
Yes
No
Do you have keratoconus?
Yes
No
Other Conditions
Any significant infectious diseases (Incl. HIV, Hepatitis)
Yes
No
Kidney or Bladder Disease
Yes
No
Sleep disorders (e.g. Narcolepsy)
Yes
No
Hearing disorders (e.g. deafness or ringing in ears)
Yes
No
Learning disorders (e.g. Dyslexia)
Yes
No
Speech disorders (e.g. Stuttering)
Yes
No
Gastrointestinal problems (e.g. ulcer, bowel disorder, liver disorder, hernia)
Yes
No
Any history or cancer, incl. skin cancer
Yes
No
Any skin conditions
Yes
No
Any allergies
Yes
No
If Yes, do you require any medication for allergies, including Epipen
Yes
No
Do you take any prescription medications (including contraceptive pills)
Yes
No
If Yes, please provide details
Do you take inhalers/puffers prescribed or over the counter
Yes
No
Are there any other medical conditions, injuries operations including day surgery, or hospitalisations for any reason that has not been declared above?
Yes
No
If Yes, please provide details
Hepatitis B Status
Have you recieved your first Hepatitis
Yes
No
Have you recieved your second and third vaccinations?
Yes
No
Have you had a blood test to confirm immunity to Hepatitis B?
Yes
No
If Yes, what was the result?
Applicant Declaration and Consent
Please ensure that you understand each of the following statements.
Please tick each box as confirmation that you have read, understood and accepted each of the statements below.
Should you require clarification of any aspect please contact WGE Group Human Resources on 02 4272 2200
I declare the information I supply as part of this application, and any documentation supporting it, is complete and correct in every detail.
I am aware any false or misleading information supplied by me will result in my application being assessed as "professionally unsuitable for WGE Employment"
I understand I am obliged to notify WGE Group of any circumstance which would alter the responses or information provided in this application.
I understand any failure on my part to notify WGE Group of any such change in circumstances will result in me being deemed "professionaly
unsuitable" and denied any opportunity for employment
I understand that my application is assessed on the information I have supplied including accompanying reports regarding my current
medical conditions and its management, including such things as spectacles, hearing aids, medications, etc. Should my medical circumstances alter any time after submitting this application, I am required in the first instance to contact WGE Group Human Resources.
I understand that my signature, if given below, represents complete agreement with each of the statements set out above.
