Medical Student Health Assessment (Page 4 of 8) in pdf

Medical Student Health Assessment Page 4

If you declare any impairment or health condition which may require us to adjust the

course programme, or affect fitness for work with patients, an Occupational Health

Adviser will contact you to assist you further within the next 2-3 weeks.

Data Protection Information:

If you join this University/School, this questionnaire will form the basis of your

Occupational Health (OH) record. If you do not join, your questionnaire will be

destroyed.

Records are held in confidence by the University/School Occupational Health

Confidentiality

Service, in line with the GMC’s guidance on

You may obtain access to your OH record by contacting the OH Clinic at xxx.

If you require further information contact the OH Service [give contact textphone,

email, fax, telephone and address]

Section 1: Personal Details

Family name: __________________ Given name(s): _____________________________

Date of birth: _________________ Male/female: __________ Title (Mr, Ms, Mrs etc) ___

Contact address: ________________________

GP's name and address: ____________

______________________________________

________________________________

______________________________________

________________________________

Tel: home _____________________________

Tel: ____________________________

Tel: mobile _____________________________

Email: _________________________________

Medical Student Health Assessment Page 4