Pre-commencement Medical History

Personal details
Surname
Employee
Number
Date of birth

Given name(s)
Gender

Email

Mobile phone

Proposed start
date
Department

dd/mm/yyyy

Home phone

Position details
Role Title

Division

Mater Health Services requires the following medical information in order to fulfil its duty of care to Mater
People under the Work Health and Safety Act 2011. This information enables Mater to take any
necessary steps to ensure that you can commence safely in the workplace
Maters Safety Health and Wellbeing Unit may contact you if any further details are required.
Maters collection, use and disclosure of personal information is in accordance with legislative
confidentiality requirements and PR-PAL-010002 Maters HR Record and Employee Access Management
Procedure.

Medical details
1. You may be required to receive vaccines as part of
your role. Is there any reason you are unable to
receive vaccines? E.g. You have not responded to a previous

Yes

No

vaccine, are pregnant, previous allergic reaction to a vaccine, etc.

Provide details here:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
____
2. Do you have any current or recent physical injuries, or have you required surgery
which may impact on your ability to perform your role? Where a pre-existing injury or illness
exists, you may be required to undergo a medical examination prior to commencement at Mater Health
Services.
Head / Brain

Neck

Back

Shoulder

Elbow

Wrist

Hand

Hip

Knee

Ankle

Foot

Other

Please name: _____________________________________

If you have indicated an injury, had surgery or are currently receiving treatment, provide date and
details e.g. aggravating factors such as prolonged standing / sitting, constant bending, time of day:

___
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Continued on next page
_________________________________________________________________________________________
Pre-commencement Medical History

Effective Sept 2015

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3. Do you currently have or have you ever suffered from any significant medical
conditions?
Cardiovascular
conditions
Hearing conditions

Diabetes

Epilepsy

Neurological conditions

Psychological conditions

Respiratory conditions

Severe allergic reactions

Skin conditions

Visual impairments

Other

Please

name:
If you have indicated a medical condition above, provide date, details of the duration and severity of the
condition, as well as details of any required treatment :

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___
4. Do you have any current medical conditions that may affect
your ability to perform your role?

Yes

No

If yes, provide details:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___
5. Will you require any adjustments to the workplace to assist
you performing your role?

Yes

No
Unsur
e

If yes, provide details. E.g. include any medical or allied health reports, certificates, etc.:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___

Acknowledgement
I acknowledge that I have disclosed all relevant information and that this information is true
and correct. I understand that should I fail to disclose all relevant information or information
which is not true and correct, I may be liable to have my appointment at Mater delayed,
withdrawn or terminated.
I understand that the information I have supplied in this form may be disclosed to relevant
Mater managers and / or People & Learning team members to ensure the provision of a safe
working environment.
Signature
Date _ _ / _ _ /_ _ _ _

Return to:
Occupational Health Team, SHAW Unit, Mater Health Services
Email
(preferred)
Fax
In person
Post

WHS1@mater.org.au
07 3163 2444
People & Learning Reception, 4th Floor, Duncombe Building
SHAW Unit, Occupational Health Team, Mater Health Services

Pre-commencement Medical History

Effective Sept 2015

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Phone
enquiries

Raymond Terrace
South Brisbane QLD 4101 (express post recommended)
07 3163 8190

Office use only

Comment
s:
Signature

Pre-commencement Medical History

Date

Effective Sept 2015

_ _ / _ _ /_ _ _ _

Page 3 of 3