HEALTH ASSESSMENT QUESTIONNAIRE

"*" indicates required fields

I consent for Caroline Malbon to complete a physical health assessment and a written report to be provided to my employer James Lynch & Sons (Transport) Ltd
Employee Name*
Clear Signature
DD slash MM slash YYYY
Health care professional Name*
Clear Signature
DD slash MM slash YYYY

Physical Health Report

Employee Name*
Left Arm
Right Arm

Chest Examination

Inspection
Auscultation
Percussion
Palpation

Muscular Skeletal Examination

ROM Left
ROM Right

Hand-Arm Vibration Syndrome (HAVS) Assessment

Allens Test*

Skin

At risk of contact dermatitis?*
Wears gloves as PPI?*
Allergies?*

Eyesight

DD slash MM slash YYYY
Glasses wearer?*

Audiology

DD slash MM slash YYYY
Do you wear any hearing aids?*

Weight Management

Diet and Lifestyle

This field is for validation purposes and should be left unchanged.

RHA Conditions of Carriage

RHA Membership Certificate

SQAS

Volvo

Zero Gravity Safety Limited (Training Provider)

Recovery Safe Training Services (Training Provider)

Dulsons Training

Peers Rooney Training

Telephone: 01270 529200
Out of Hours: 01270 529200

Address

James Lynch & Sons (Transport) Ltd.
Norton Way,
Moss Lane Industrial Estate,
Sandbach,
Cheshire,
CW11 3YT