Night worker questionnaire - Centrica MyHealth Step 1 of 6 16% Important information before you startIt is important that your answers are complete and accurate and submitting this form will indicate that you have answered the questions truthfully to the best of your knowledge. This is to ensure that healthcare rm, who deliver the Centrica MyHealth service, can provide you with the most appropriate advice in relation to your health and the work that you undertake on behalf of Centrica. Failure to be completely honest could be detrimental to your health.The information you provide is Private and Confidential and the only information Centrica receive will be a Certificate of Fitness which will be uploaded to Workday for both you and your manager to see.Any medical information is kept confidential and held securely by healthcare rm in line with Data Protection Law. This will not be shared with your employers without your consent.If you have any questions regarding the completion of the questionnaire you can call healthcare rm on: 0333 577 8776. About youHiddenEmployer Pass through testHidden client nameCentricaMyHealthName* First Last Address* Street Address City County Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Best contact number* Email address* Job title* Employee ID number* Work detailsYour location of work Name of your line manager* Contact number of line manager* AssessmentComplete the following to the best of your knowledge. Ticking 'Yes' does not mean you will not be fit for night work but that a further assessment by healthcare rm may be required.Do you suffer or have you ever suffered from dizzy spells/fits/blackouts?* Yes No Do you suffer from high blood pressure?* Yes No Do you suffer from diabetes?* Yes No Is it controlled by insulin, tablets or diet? Yes No Have you noticed any change in your thirst or passing more urine?* Yes No Have you had any unexplained weight loss/gain recently?* Yes No Do you have heart or circulatory disease of any sort?* Yes No Do you ever get chest pains?* Yes No Do you experience shortness of breath, wheezing or bouts of coughing?* Yes No Do you have asthma or chronic bronchitis?* Yes No Have you had peptic or duodenal ulcers or any bowel disease?* Yes No Have you had depression, “stress”, nervous disorders or other psychological illness, alcohol or drug addiction?* Yes No Do you have any condition requiring regular medication at strict times, i.e., epilepsy, thyroid disease?* Yes No Have you received treatment from a doctor for any Sleep Disorder?* Yes No Do you have any other health condition which you might wish to discuss with healthcare rm?* Yes No As you have answered 'Yes' to one of the above questions, please give further details* Lifestyle (optional)Completing this section of the questionnaire will not affect the outcome of your assessment. However, the information provided will enable us to support your health and wellbeing in the future.Height (cms) Weight (kgs) Smoker No Yes How many (per day) Alcohol (per week)One alcohol unit is measured as 10ml or 8g of pure alcohol. This equals one 25ml single measure of whisky (ABV 40%), or a third of a pint of beer (ABV 5-6%) or half a standard (175ml) glass of red wine (ABV 12%). You can work out your alcohol units with this handy sum: Strength (ABV) x Volume (ml) divided by 1000 = No. of units 0 Units < 5 Units 6 - 10 Units 11 - 15 Units 16 - 20 Units 21 - 25 Units 26 - 30 Units > 30 Units How much physical activity do you do (per week)?Physical activity counts when your heart rate and breathing are elevated, so that you begin to sweat and are slightly out of breath for extended periods of time i.e. over 10 minutes 0-1 hours 1-2 hours 2-3 hours 3-4 hours 4+ hours DeclarationPlease read this declaration carefully before submitting: I declare that all foregoing statements are true to the best of my knowledge. I understand that I may be required to attend for consultation with a healthcare rm case manager or that I may be required to undergo a medical examination.Information for applicantsData Protection Lawhealthcare rm will treat the information you provide on this form in a strictly confidential manner and it will be held in accordance with the principles of medical ethics and relevant legislation. If you require reasonable adjustments to your job and workplace (e.g. for reasons of health and safety) and/or where any such adjustment is necessary for your personal protection (e.g. epilepsy, type 1 diabetes, functional disability), information about the adjustments required (but not your underlying medical condition) may be divulged to your employer for the purpose of determining whether any adjustments are required or can be made to the post for which you have applied.Equality Act 2010 (Disability)This form enables healthcare rm to assess your medical fitness against the specific requirements of the post for which you are being considered. If you have a disability or impairment, the information you give us about it on this form will help us to ensure that any reasonable adjustments you may require are considered properly. The information you give us will also provide baseline data for any future health assessment(s) that may be made during your employment.Contact AddressIf you have any questions please write to healthcare rm, Ashvale, Ashchurch Business Park, Alexandra Way, Tewkesbury, Gloucestershire, GL20 8NB or email to ost@healthcare-rm.comI confirm my agreement with the above declaration* Please tick here CAPTCHA