Project Picnic Consultation Form If you wish not to answer any section or any questions due to not being applicable or related to you, please write NA (Not applicable). For any other personal reason, please write prefer not to answer. If you need any assistance or have questions in filling in the form, please do not hesitate to ask the nurse. Thank you. Personal Details First Name (and Middle/Other Names) Last Name Date of Birth (tap on Year e.g. 2021 to change year) Email Contact Telephone/Mobile Number Company Job Title / Position Lifestyle Check Smoker? Yes No Ex-smoker How many cigarettes / cigars / pipe / roll ups do you smoke at present? If an ex-smoker, when was the last time you smoke? If an ex-smoker, how many cigarettes did you use to smoke on a daily / weekly / or monthly basis? Do you use e-cigarette at present? Yes No Do you have a partner, family member, relatives, friends or anyone who may have caused passive smoking? Yes No Do you live with someone who smoke? Yes No Do you drink alcohol Yes No Occasionally Rarely How many units of alcohol intake? Do you exercise? Yes No What do you do for exercise and how frequent do you do this? Diet Normal Vegetarian Vegan Pescetarian GlutenFree LactoseFree Ketogenic Diabetic LowCarbohydrate SouthBeach IntermittentFasting Other Medical History Do you have fever today or in the last couple of days? Yes No Do you have any Covid-19 related symptoms at present? Yes No Have you had Covid-19 in the past? Yes No Maybe Have you suffered from any dizziness, head injury or concussion? Yes No Other Have you got a visual problem or disturbances? Yes No Other Do you have problems in your smell? Yes No Do you have difficulty swallowing? Yes No Do you have any lung problem? Yes No Do you have any heart problem? Yes No Do you have hearing difficulties or any ear problem? Yes No Do you get frequent mouth sores? Yes No Do you get swollen gland or swollen lymph node? Yes No Do you have any stomach or gastrointestinal issue? Yes No Do you have problem in your bowel movement? Yes No Do you have any pain or problem in urinating? Yes No Do you suffer from joint pain? Yes No Do you have any musculoskeletal problem? Yes No Do you have tremors, unexplainable hand shaking or numbness or tingling in your hand /fingers? Yes No Do you have any mental health issue? Yes No Are you currently taking any medication for any medical condition? Yes No Other Any history of cancer or cancer treatment? Yes No Other Have you got any problem with any body parts or internal organ? eg diabetes, epilepsy, thyroid problem, hepatitis, HIV, immune system problem, skin condition, significant allergy Yes No Other If you have answered yes to any of the questions above, please provide more details Signature for consent* Clear Use your mouse or finger to draw your signature in the box I, hereby, confirm that if required I will be self-isolating and/or in quarantine for the required time (if applicable) and I have no symptoms of COVID-19 and I have not come in contact with anyone infected with COVID-19 in the recent past. I confirm the information provided is accurate to the best of my knowledge. I agree to have this health test done and to have the clinical support from the occupational health team including storing my data and for the organisation to report any notifiable disease to PHE, GP, and other health and social care services as needed.
