We may be able to carry out remote/paper-based assessments for periodic medical surveillance under CAR, for both licensed/non-licensed work with asbestos, giving a six month or one year certificate.
To do a remote/paper-based medical, please complete and return the questionnaire below to Dr. Helen S Bryden, helen@brydenmedical.com.
The HSE has issued new guidance in relation to Control of Asbestos Regulations 2012 (please see below) on 3rd September 2020.
For periodic medical surveillance under the Control of Asbestos Regulations 2012 , please complete and return the respiratory questionnaire below to Dr. Helen S Bryden, helen@brydenmedical.com. Thanks.
Respiratory Symptom Questionnaire
Name______________________________ Date of Birth__________________
Address___________________________________________________________
Contact details Phone ______________________Email ____________________
Job Title____________________________________________________________
Employer’s name:____________________________________________________
Respiratory Symptoms
- Have you ever, or since your last examination had:
(a) An injury or operation affecting your chest? Yes No
(b) Pleurisy? Yes No
(c) Pulmonary tuberculosis Yes No
- Do you usually cough during the day (or at night when on night work) Yes No
- Do you usually bring up any phlegm from your chest on most days (or nights) Yes No
for as much as three months each year?
- Do you usually get short of breath when walking with people of your own age Yes No
on level ground?
- During the past three years, or since your last examination, have you had any chest illness, which has kept you from your usual activities for as much as a week? If NO, go to question 8 Yes No
- Did you bring up more phlegm than usual in any of these illnesses? If NO, go to question 8
Yes No
- How many illnesses like this have you had in the past three years or since your last medical?
- Have you ever smoked? If NO, please go to Q11 Yes No
- (a) Do you smoke at present? Yes No
(b) Have you given up smoking in the last month? Yes No
(c) How old were you when you started smoking regularly? Enter age in years
(a regular smoker is defined as one who has smoked as much as one cigarette a day, one small cigar per day or one ounce of tobacco a month, for as long as a year)
(d) How many manufactured cigarettes do you usually smoke or were you smoking per day?
(e) How much tobacco do you usually smoke or were you smoking per day?
Enter number of grams (1 ounce = 28 grams
10. Ex-Smokers only – How old were you when you last smoked?
11. How long have you worked with asbestos?
12. Which firms have you worked for?
Any other comments about your health that you would like to make?
To the best of my knowledge, the information which I have given is correct and I give my consent to this medical assessment, which is for the purpose of health surveillance under the Control of Asbestos Regulations. I authorize the release of medical information from this assessment to my G.P. if necessary. I understand that confidential information about health and medical history will be confidentially treated, processed and stored in a secure environment by Bryden Medical Limited and will only be accessed and processed by those staff that have explicit and reasonable need to do so, with due consideration for Data Protection (GDPR 2018).
Signed: ____________________________Print Name: _____________________________ Date: ___________________________________
Please email completed forms and any questions to Dr Helen Bryden at helen@brydenmedical.com Thank you.
Registered in Scotland SC323357
