We are now open again for medicals and lead tests.
Name__________________________________ Date of Birth______________
Address___________________________________________________________
Contact details Phone ______________________Email ____________________
Job Title____________________________________________________________
Employer’s name:____________________________________________________
How long have you worked with lead? _________________________________
What was your last blood lead measurement? _________________________
Do you have or have you had previously:
Symptoms of anaemia or tiredness? Yes No
Nerve damage or neurological problems? Yes No
Kidney problems or high blood pressure? Yes No
Cancer Yes No
Infertility? Yes No
Headaches? Yes No
Irritability or mental health issues? Yes No
Constipation, nausea, stomach pains or loss of weight? Yes No
Any other health issues? Yes No
Do you smoke? Yes No
Further information about your health?
Also an unborn child is at particular risk from exposure to lead, especially in the early weeks before a pregnancy becomes known.
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 Lead at Work 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.
