HGV-MF216 Health Questionnaire

HGV Questionnaire

Personal details

First Name *

Last Name *

Course Name*

NI Number *

This self assessment questionnaire is designed to assess your own health in the context of training with Mainstream.

It is recommended that you complete it in person, as you may identify some health problems. Mainstream will then be able to advise you on what actions are required and if necessary adapt your training programme to suit you. The information you provide would, of course, be treated as confidential and would be used only for this specific purpose.

Do you have any previous experience in the course you have named above? *

For your own safety

Have you ever had any back or joint condition or other injury that may be aggravated by work or training? (If Yes, Please give details below)*

Have you undergone an operation or treatment for any condition that affects your ability to lift or move objects? (If Yes, Please give details below) (If Yes, Please give details below)

Have you ever had a heart condition, high blood pressure, rheumatic fever, stroke, high cholesterol, palpitations, angina, murmurs or pains in the chest? (If Yes, Please give details below)

Do you or have you had a problem with your arms, hands, shoulders, legs or knees that may affect your ability to lift or move objects? (If Yes, Please give details below)

Do you suffer from or have you ever had any of the following: arthritis, asthma, circulation problems, diabetes, dizziness, vertigo, epilepsy, hernia, gout or an ulcer? (If Yes, Please give details below)

Are you a smoker?

Have you suffered a serious head injury in the last 10 years?

Do you have a medical condition that causes daytime sleepiness?

Can you read a car number plate at 20 metres? (cat C or C+E only)

Have you completed an Eye Test within the last 2 years? (Cat C or C+E only)

Any learner that carries out Cat C or C+E Licence acquisition must have had an eye test within 2 years of their LGV medical date. You must produce proof of this at the LGV medical. (cat C or C+E only)

Are you now or have you recently been pregnant? (ladies only)

Are you taking any prescribed or un-prescribed medication? (If yes, please give details of medication below)

Does this medication affect your physical or mental ability in any way?

Do you suffer from any conditions that could be induced by flashing lights?

Are there any other conditions that might be a concern to you? (including learning disabilities) (If Yes, Please give details below)

Please list any additional information that you feel is relevant for us to be aware of or any other areas of concern, including prescribed medication:

Health, safety & fitness

Describe your physical condition:

Declaration

I have completed the above questionnaire and I understand that the information I have given is supplied in confidence and will be used only as a basis for advice.

Signature:

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Date: Saturday, 22nd February 2025