Are you currently taking any prescription medication? *

Yes

No

Have you had a hearing test? *

Yes

No

Do you have any other related hearing issues, Tinnitus, Hearing Aids? *

Yes

No

Do you, or have you ever suffer/ed from any injury, serious illness, any physical or other disability,which might restrict the performance of your duties? *

Yes

No

If requested, do you have a Certificate of Capacity that can be produced? *

Yes

No

Are you aware of any reasons of why you would struggle to perform your duties? *

Yes

No

Are you currently being treated by a Doctor for any illness? *

Yes

No

Are you currently taking any prescription medication? *

Yes

No

Are you allergic to anything or have allergies? *

Yes

No

Do you suffer or have you ever suffered from any of the following: *

Lung Problems

Yes

No

Diabetes *

Yes

No

Heart disease, heart surgery, murmurs, palpitations, angina, heart attack *

Yes

No

Stomach pains or ulcers *

Yes

No

Thyroid disease *

Yes

No

Head or spinal injury *

Yes

No

Eyesight problems *

Yes

No

Cancer *

Yes

No

Sleep disorder *

Yes

No

Elbow / Wrist / Hand pains *

Yes

No

High Blood Pressure *

Yes

No

Hernia or Rupture *

Yes

No

Epilepsy / Fits / Black Outs *

Yes

No

Skin Disorders / Dermatitis etc. *

Yes

No

Anxiety / Depression / Stress *

Yes

No

Liver Disease / Hepatitis *

Yes

No

Neck / Back / Shoulder Pain *

Yes

No

Hips / Knees / Ankle / Feet Pain *

Yes

No

Have you ever had any injury or condition that would affect your ability to perform the following tasks *

Standing

Yes

No

Bending *

Yes

No

Walking *

Yes

No

Squating *

Yes

No

Working for a duration of 8-12 hours *

Yes

No

PRS will conduct a functional test of 6 exercises to ensure suitability for work. *

Do you agree to undertake this test?

Yes

No

I confirm that the information provided in this form is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in appropriate actions being taken. *

Name

First Name

Last Name