Name_____________________________________ Date of Birth_____________
Address___________________________________________________________
Contact details Phone ______________________Email ____________________
Job Title___________________________________________________________
Employer______________________ Number of years with employer________
Duration worked on current installation (if core crew/regular rotation) _______
Rota Worked_______________________________________________________
Number of years working offshore_____________________________________
Previous roles offshore______________________________________________
Social history_______________________________________________________ (relationship status, responsibility for childcare/other family members) and family history of medical conditions)
Medical questionnaire: Do you have/have you had a history of any of the following?
Any new problems with your health since your last OGUK medical Yes No
COVID-19 Yes No
History of now inactive medical problems Yes No
Ongoing chronic conditions (e.g. diabetes, cardiovascular disease ). Yes No
Are you prescribed or do you take any medication Yes No
Asthma /bronchitis Yes No
Varicose veins or haemorrhoids Yes No
High blood pressure/hypertension Yes No
Heart conditions/rheumatic fever Yes No
Disease of the brain/ nervous system Yes No
Head injury or concussion Yes No
Sleep disorder Yes No
Migraine/severe headaches Yes No
Tobacco use: Yes No
Type/amount of tobacco
Alcohol intake per week Units
Back injury/pain/joint problems Yes No
Ear/nose/ throat/sinus/hearing problem Yes No
Eye trouble/squint/glasses/contact lenses Yes No
Diabetes or other hormone problems Yes No
Urinary/ kidney /for men, prostate/for women, gynaecological problems Yes No
Stomach /bowel disorder/ jaundice/liver disease Yes No
Skin disease Yes No
Fractures/dislocations Yes No
Any other health issues Yes No
Comments on medical history:
To the best of my knowledge the information which I have given is correct. I give my consent to this medical assessment. I understand that the purpose of this medical is to provide information regarding fitness for work and that any advice given will be expressed in terms of fitness for employment and / or fitness to carry out duties now and in the future. 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.
GPs Name______________________________________________
GP Address: _____________________________________________
GP’s comments on above questionnaire______________________
_______________________________________________________
From GP records: Height____ cm, Weight____ kg, BP____/_____
Visual Acuity _____________
Employer’s/Agency’s Statement:
Employee Name________________________ Date of Birth_______
Job Title___________________________
Do you have any information regarding sickness absence, medevac, missed check‐ins, or other medical concerns that you would like to share, which may help in relation to the OGUK medical examination? Yes No
If yes, please give details.
Name_________________ Role_______________ Date_________
Thank you. Please return to Dr. Helen S Bryden on helen@brydenmedical.com
Bryden Medical Limited Registered in Scotland SC323357
