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Applicant Medical Questionnaire
Mandatory completion by all candidates
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* Indicates required question
Email
*
Your email
Emergency contact Name
Your answer
Emergency contact number
Your answer
Do you or have you ever had treatment for any of the following ?
Lungs – asthma, bronchitis, pneumonia, pleurisy, TB or other lung disease?
Hay fever, allergies or hives?
Heart – Rheumatic fever, high blood pressure, heart disease, heart murmur, raised cholesterol, angina, palpitations or any chest pain?
Diabetes, thyroid disease or any glandular problems?
Fits, blackouts, epilepsy, head injury, severe headache, migraine?
Stroke, paralysis, impaired walking?
Impaired vision, any eye disease, wear glasses or contact lens?
Psychological problems - Psychosis, depression, anxiety, panic attack?
Claustrophobia, agoraphobia, fear of heights, enclosed spaces etc?
Neck, back or spinal injury or chronic or recurrent back pain?
Did you ever attend a doctor for back pain?
Any visits to hospital or admission unrelated to previously mentioned problems?
Any other x-rays/ scans or anaesthetics other than those already mentioned?
Have you had any physical injury in the last 18 months (including breaks, sprains, soft tissue damage or concussion)
Are you allergic to any medications, food, chemicals, animals, plants or have you had any adverse reaction to any, please state
Your answer
Date of last Tetanus vaccination? (Please boost immunity if over 10 years ago)
MM
/
DD
/
YYYY
Are you currently taking any medication? if yes please state the medication
Your answer
Have you had any physical injury in the last 18 months (including breaks, sprains, soft tissue damage or concussion) If yes please explain
Your answer
Are you currently or have you been in the last 24 months under the care of a mental health support person (counsellor, psychiatrist, bereavement specialist, suicide prevention team) or have you been treated in an emergency situation for any mental health challenges? This information is required if you intent to be a resident in RACE We have limited professional supports available on campus.
Your answer
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