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Online application

Medical application

Fields marked * are required. Your information is stored securely and only seen by the ABC team.

Medical

Leave blank for a new employee
Where and when your last medical was done, if any
e.g. worked in a noisy factory for 5 years

Your details

So we can send you a link to update your application

Job details (Annexure 3)

The employer must supply this information. If your employer gave you a list, copy it here. Tick everything that applies to the job.

e.g. general worker, welder, bricklayer, forklift operator
Possible exposures
Job-specific requirements
Protective equipment

Work history

Are you comfortable to work in confined spaces?
Are you working on heights?
Are you working on ladders?
Are you using ropes to do your work?
Are you afraid of heights?
Will you prepare, serve or handle food in your job?
Exposure to hazards identified

Family history

Has anyone in your close family (parents, grandparents, brothers or sisters) had:

Heart disease
Hypertension (high blood pressure)
Diabetes
Asthma
Epilepsy
TB
Cancer
Mental illness
e.g. grandfather had heart disease

Medical history

Have you ever had, or received medical treatment for, the following? Only the ABC medical team sees your answers.

1. Heart condition (angina, pacemaker)
2. High blood pressure or stroke
3. Diabetes mellitus
4. Respiratory: TB, asthma or chronic cough
5. Head injury, fits or headaches
6. Ear, nose or throat problems
7. Skin disorders (psoriasis, eczema)
8. Any allergies
9. Abdominal pain, nausea, vomiting, bowel problems, heartburn or chronic gastritis
10. Kidney disease or problems
11. Disease of the reproductive system
14. Have you ever had an injury on duty?
16. Have you taken medication recently?
17. Do you suffer from epilepsy?
18. Do you suffer from back pain?
19. Can you lift 30 kg without back pain?
20. Ever admitted to hospital for any reason?
21. Any operations?

Drug test: medication declaration

A urine drug screen (5-panel) is part of your medical. Some medicines can affect the result, so please list them.

Have you used any prescription medication in the past 30 days (including chronic medication)?
Have you taken any over-the-counter medication in the past 14 days (e.g. pain, cold & flu tablets)?
Have you taken any other drugs or medication not mentioned above?

Working on heights questionnaire

Because you work on heights, please also answer these questions.

Do you take medication for a chronic illness (high blood pressure, diabetes, asthma)?
Are you on any other medication (not chronic)?
Do you suffer from fear of heights (higher than 1.8 metres)?
Do you suffer from anxiety, suicidal thoughts and/or depression?
Do you suffer from dizziness or blackouts?
Have you ever had seizures (epileptic fits), even as a child?
Do you use medication from a psychologist or psychiatrist?
Any history of ear problems?
Do you use any type of drugs, e.g. dagga, tik, cocaine, mandrax?

Food handlers questionnaire

Because you will handle food, please also answer these questions.

At present or in the last 7 days: diarrhoea and/or vomiting?
At present or in the last 7 days: stomach pain, nausea or fever?
At present: skin infections of the hands, arms or face?
At present: discharge from the eye, ear, gums or mouth?
At present: jaundice?
Do you suffer from a recurring bowel disorder?
Recurring infections of the skin, ear or throat?
Have you ever had typhoid fever?
Are you a carrier of any type of salmonella?
In the last 21 days, contact with anyone (at home or abroad) who may have had typhoid?
Visited other countries in the last 6 weeks?

Documents

PDF, JPG or PNG, up to 8 MB each. On a phone you can take a photo directly.

Clear photo or scan of both sides
For periodic medicals
If you answered "Yes" to a medical history question
If your employer gave you a completed Annexure 3 page

Declaration

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