Please answer all sections and questions as completely as possible. If additional information is required or if clarification is required an occupational health nurse or doctor may contact you.

If you indicate yes to any of the questions listed please name the illness, date when symptoms started and when the diagnosis was made. State if you attended a doctor, specialist or health facility and if investigations were carried out and the results of such investigations.

Please give details of any treatment you may have had such as surgery/medication and state if you are currently taking medication and/or having treatment such as physiotherapy etc.

  • If you required time off work please indicate when this was and for how long.
  • If you have not fully recovered from your illness please state how this affects you.
  • If you believe your illness is work related please give details.