Medical Surveillance Questionnaire


A medical surveillance questionnaire is issued for the purpose of timely detection of any existing medical conditions. The aim of this is to identify conditions that may cause negative effects in relation to tasks or duties being performed. This is dependent on the kind of work involved and how the condition may be exacerbated by the work. The factors considered include the nature of the job and potential exposure to certain materials. In such cases, a medical surveillance questionnaire is used to gather information in line with the job requirements and occupational hazards. This is necessary for the medical monitoring of employees in certain work environments.

Sample Medical Surveillance Questionnaire

The information provided in this questionnaire is strictly confidential.

Name………………………………Date of birth…………………………….

Office number………………………………………………

Mobile phone number…………………………………..

E-mail address…………………………………………………

Title……………………………………………………………….

Department………………………………………………………

Address………………………………………………City………………………………Zip code………………………..

How often do you come into contact with the animals in the laboratory? …………………………………………..

On average, how much time do you spend with these animals on a daily basis (in hours)? ………………………

Please specify the type of animals and time spent with each of them…………………………………………………….

Have you experienced any symptoms that arise when you work with the animals? ……………………

Please place a tick against the symptoms that you have experienced

a.Sneezing

b.Watery eyes

c. Coughing

d.Skin rash

e.Chest pain

Are you currently taking medication for the aforementioned symptoms? ………………………………………………..

If you are, please specify…………………………………….

Do you have a medical history that constitutes respiratory diseases? If yes, specify and briefly describe course of treatment………………………………………………………………………………………………………………………………..

Do you have any allergic reactions?  ………………………………………..

Do you smoke cigarettes?  ………………………………………………………….

Please name the conditions that you have been vaccinated against? ………………………………………….

Category: Medical Questionnaire

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