Do you think that you may require special adjustments or certain equipment in order to complete the tasks involved in your role as a performer Yes No If yes, please give details: Have you ever had any health condition / impairment / disability which may have been caused or made worse by your work? Yes No If yes, please give details: Are you taking any regular prescribed medication? Yes No If yes, please give details: Are you having or waiting for treatment or investigations at present? Yes No If yes, please give details: Have you ever been treated for Mental Health problems (including anxiety, depression, eating disorders, alcohol or drug Yes No If yes, please give details: Musculoskeletal problems including any difficulties in standing bending lifting or other movements (back pain, arthritis, pains in upper limbs, lower limbs, neck, shoulder) Yes No If yes, please give details: Skin problems (including eczema, dermatitis, or associated allergies (e.g. latex) Yes No If yes, please give details: Do you have any of the following: Cough lasting more than 3 weeks? Yes No Unexplained weight loss? Yes No Unexplained fever? Yes No Have you had tuberculosis or been in recent contact with someone with TB? Yes No Have you lived / worked continuously in the UK for the last 5 years? Yes No If No, please give details: If no please indicate which countries you have lived / worked: SECTION C: Immunisations Please include documentary evidence of all vaccines dates Tuberculosis BCG Immunisation date / / Scar present: Yes No
Do you think that you may require special adjustments or certain equipment in order to complete the tasks involved in your role as a performer Yes No If yes, please give details: Have you ever had any health condition / impairment / disability which may have been caused or made worse by your work? Yes No If yes, please give details: Are you taking any regular prescribed medication? Yes No If yes, please give details: Are you having or waiting for treatment or investigations at present? Yes No If yes, please give details: Have you ever been treated for Mental Health problems (including anxiety, depression, eating disorders, alcohol or drug Yes No If yes, please give details: Musculoskeletal problems including any difficulties in standing bending lifting or other movements (back pain, arthritis, pains in upper limbs, lower limbs, neck, shoulder) Yes No If yes, please give details: Skin problems (including eczema, dermatitis, or associated allergies (e.g. latex) Yes No If yes, please give details: Do you have any of the following: Cough lasting more than 3 weeks? Yes No Unexplained weight loss? Yes No Unexplained fever? Yes No Have you had tuberculosis or been in recent contact with someone with TB? Yes No Have you lived / worked continuously in the UK for the last 5 years? Yes No If No, please give details: If no please indicate which countries you have lived / worked: SECTION C: Immunisations Please include documentary evidence of all vaccines dates Tuberculosis BCG Immunisation date / / Scar present: Yes No
Performers_List_Health_Assessment_Form_-_updated_31012014.docx