General Health
Student health professionals undertake work placements requiring physical activity for several hours a day. Those who have serious disorders of major organs such as the heart, lungs, kidneys, liver or who have a systemic illness that undermines their physical stamina, may be unable to meet this requirement. Exposure to illness environments might also be detrimental to some students’ general health.
Study, exams, work, placements and/or the associated travel may be stressful to some students and potentially could exacerbate medical/mental health conditions. Students experiencing difficulties need to be proactive if this is the case and seek help/support without delay.
Additional Sources of Advice and Support Skill National Bureau for Students with Disabilities: http://www.skill.org.uk
Royal National Institute for the Blind: http://www.rnib.org.uk
Royal National Institute for the Deaf: http://www.rnid.org.uk
Scottish Association for Mental Health: http://www.samh.org.uk
World of Dyslexia: http://www.dyslexia-parent.com/world_of_dyslexia.html
Glasgow Caledonian University Disability Service: http://www.gcu.ac.uk/student/disability/index.html
Pre-Joining Health Form
This health assessment forms part of the admissions procedures of the School of Health and Life Sciences at Glasgow Caledonian University. This form must be filled in and returned to:
(name) .................................. (address)....….....…………….…................ by .......…….......... (date).
The purpose of pre-admission health assessment is two fold: to ensure that you are fit to successfully complete the programme for which you have applied to study and to assist the School in facilitating your learning by making identified reasonable adjustments and/or providing additional appropriate support. Questions are asked about your past and present health, and the information you provide will be accessible only to the Occupational Health staff and will remain confidential; however in order to allow the university to make reasonable adjustments and provide the necessary support, adequately pertinent information should be disclosed to the Programme Leader. The attached explanatory notes summarise the purpose of the questions. Forms of candidates who do not enrol on a programme, of students who leave the university before completing a programme, and of graduates will be returned to the student or destroyed within x months of ….... If you have any questions regarding the purpose of this form and how to complete it, please contact …………………...................
Surname:
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Sex:
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Forenames:
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Address:
Postcode:
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Home Telephone Number:
Mobile or Contact Number:
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Name, address and phone no of General Practitioner:
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IMMUNISATION HISTORY
Please complete the following table.
Have you had the following
Immunisation / Test / Infectious Disease
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Yes
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No
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Year/date
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Test result where relevant
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Tuberculosis (TB) test
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BCG (TB immunisation)
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Poliomyelitis immunisation
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Tetanus immunisation
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Diptheria immunisation
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Chickenpox or herpes zoster infection
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Varicella (Chickenpox/herpes zoster) blood test
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Varicella immunisation
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Rubella (German measles) blood test
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Rubella Immunisation
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Measles Immunisation
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Hepatitis B immunisation: 1st dose
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Hepatitis B immunisation: 2nd dose
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Hepatitis B immunisation: 3rd dose
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Hepatitis B booster dose
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Hepatitis B blood test
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Other (specify):
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Chronic carriers of blood borne infectious diseases (such as Hepatitis B, Hepatitis C or HIV) are not necessarily excluded from working or training in a health care setting. If you have any questions or are unsure as to your current status please contact ……………………………………………………………………
Please answer all the following questions Yes or No and if yes, please give details in the space provided.
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Yes
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No
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Details
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Are you having treatment of any kind at the moment?
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Are you waiting for any treatment or investigation?
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Have you been seen or examined by a doctor in the last 6 months?
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Do you have any impairment of sight that is not fully corrected with glasses?
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Do you have any impairment of hearing that is not fully corrected with a hearing aid?
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Do you have any impairment of speech?
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Do you have dyslexia or any other learning difficulty?
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Do you have any physical limitation which may affect your ability to practise?
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Have you ever had any kind of back or neck problem leading to time off work/school?
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Have you ever had any kind of problems with your joints, including pain, swelling or restricted movement?
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Do you have any difficulty in standing, bending, squatting, lifting or any other movements?
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Do you have any loss of sensation, numbness or tingling in your hands and/or upper limbs?
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Have you ever had any neurological condition?
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Do you have diabetes?
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Have you ever had seizures, blackouts or epilepsy?
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Have you ever had asthma, bronchitis or chest problems?
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Have you ever sought help for mental ill health?
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Yes
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No
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Details
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Have you ever had anorexia nervosa or bulimia or any other eating disorder?
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Have you ever had professional help for a life crisis or other emotional or psychological stress?
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Have you ever had a drug or alcohol problem?
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Have you ever received treatment for a gastric or bowel problem?
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Have you ever had heart, circulation or blood pressure problems?
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Do you have any allergies?
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Have you ever had any kind of skin condition?
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Have you ever had tuberculosis (TB)?
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In the last 12 months, have you had a cough for more than 3 weeks, coughed up blood, or had any unexplained weight loss or fever?
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Have you ever had hepatitis or jaundice?
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Do you have any chronic blood borne viral infection (e.g. Hepatitis B, Hepatitis C or HIV)?
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Do you have any other condition not mentioned above?
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Yes
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No
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Do you smoke?
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If so, on average how many per week?
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Do you drink alcohol?
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If so, on average how many units per week?
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If you have an impairment or a physical or mental health condition, in what way, if any, and to what extent do you think it could impact on the success of your training programme, including practical placement work?
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COURSE FOR WHICH YOU HAVE APPLIED
Title of Programme:
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UCAS Code:
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Starting date:
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DECLARATION
I declare that all of the above statements and information are true to the best of my knowledge. I understand that making a false declaration may result in the withdrawal of the offer of a place on the programme for which I have applied and that failure to return the form on time or to give full information may hinder the University putting in place reasonable adjustments and therefore adversely affect my learning experience.
Signature: ___________________________________________________ Date: _____
SCHOOL OF HEALTH AND LIFE SCIENCES
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