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Full name
Date of Birth
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MM
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YYYY
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Occupation & Duties
(e.g. 80% computer work, 10% driving, 10% admin)
Have you smoked, vaped or used and E-cigarette in the last 12m?
Yes
No
Height
Weight
Have you ever been to hospital for an operation or treatment?
Yes
No
If yes - explain briefly
Are you on any regular medication, receiving advice or monitoring for a medical condition?
Yes
No
If yes - explain briefly
Have you ever suffered symptoms of or been diagnosed with problems in the following areas?
Cancer or tumour
Yes
No
Knees, hips or back
Yes
No
Arthritis
Yes
No
Heart or arteries / cholesterol
Yes
No
High blood pressure
Yes
No
Diabetes
Yes
No
Anxiety, depression or mental disorders
Yes
No
Asthma or lung disorder
Yes
No
Drug or alcohol dependency
Yes
No
Kidney/Liver disease or disorders
Yes
No
Sleep problems
Yes
No
Blood disorders incl. HIV/AIDS
Yes
No
Chronic fatigue or pain
Yes
No
Other illness or condition not stated
Yes
No
In the last 5 years have you dealt with ACC over an injury?
Yes
No
Parents or siblings suffered from serious illness/condition
Yes
No
(e.g. heart attack, cancer etc)
If yes – explain briefly
Do you participate in any hazardous activities e.g. Scuba diving, motor sport, parachuting, rock gliding, mountain climbing, caving, hang gliding etc? Hunting – Aerial/non-aerial
Yes
No
If yes – provide details
Full Name
Date of Birth
DD
*
MM
*
YYYY
*
Occupation & Duties
(e.g. 80% computer work, 10% driving, 10% admin)
Have you smoked, vaped or used and E-cigarette in the last 12m?
Yes
No
Height
Weight
Have you ever been to hospital for an operation or treatment?
Yes
No
If yes - explain briefly
Are you on any regular medication, receiving advice or monitoring for a medical condition?
Yes
No
If yes - explain briefly
Have you ever suffered symptoms of or been diagnosed with problems in the following areas?
Cancer or tumour
Yes
No
Knees, hips or back
Yes
No
Arthritis
Yes
No
Heart or arteries /cholesterol
Yes
No
High blood pressure
Yes
No
Diabetes
Yes
No
Anxiety, depression or mental disorders
Yes
No
Asthma or lung disorder
Yes
No
Drug or alcohol dependency
Yes
No
Kidney/Liver disease or disorders
Yes
No
Sleep problems
Yes
No
Blood disorders incl. HIV/AIDS
Yes
No
Chronic fatigue or pain
Yes
No
Other illness or condition not stated
Yes
No
In the last 5 years have you dealt with ACC over an injury?
Yes
No
Parents or siblings suffered from serious illness/condition
Yes
No
(e.g. heart attack, cancer etc)
If yes – explain briefly
Do you participate in any hazardous activities e.g. Scuba diving, motor sport, parachuting, rock gliding, mountain climbing, caving, hang gliding etc? Hunting – Aerial/non-aerial
Yes
No
If yes – provide details
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