Peha + Da Consent Form - WA

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Consent Form*
1) I give permission for the assessor to conduct a pre-employment assessment, in order to
determine and document the physical capacity demonstrated at the time.

2) I am aware that I will not be required to perform and activities / assessments that I do not
feel comfortable performing. If I choose to not perform a task, the reason provided will be
documented in the reporting of results.

3) I am aware that during the assessment, I may cease performing a required task should I
feel incapable of completing such and/or concerned of my health and safety.

4) I am aware that a pre-employment task may be ceased at the discretion of the assessor
at any stage, if the performance of the task is deemed unsafe.

5) I am aware that I should advise the assessor immediately should I experience difficulties
with any tested pre-employments tasks.

6) I declare that all the information provided in the medical consent form and during the
performance of the assessment is an accurate representation of my medical / functional
capability at the time.

7) I give permission for the collection of specimens via urine and/or breath analysis for the
purpose of Drug and Alcohol testing.

8) I give permission for the assessor to release information to Recovery Partners and the
employer regarding the results of the assessment.

9) I agree that providing an electronic signature is a sufficient means to indicate my
understanding of the pre-employment assessment, and that I have provided an accurate
representation of my medical background / capacity to the best of my knowledge.

I agree to undertake a pre-employment examination with recovery partners. The examination will include; medical testing, strength and flexibility testing, cardiovascular (fitness) testing, injury screening, postural tolerances and vision testing.

I agree to the information contained in this document being used to determine my current health status and personal safety requirements and my ability to perform the role for which I am being assessed. The answers given to the below questions are true and correct to the best of my knowledge.

I acknowledge that I have read and agree to the above, and therefore give consent to all terms.

Signature*
Your Name
Your Name
Your Name
Date*

Medical Questionnaire
Name*
First Last
Date of Birth*

Sex*

Male

Female

Intersex / Non-binary / Other
Email*

Phone Number*
Do you predominately use your left / right or both hands to complete daily activities [i.e. writing].*

Right

Left
Employment History: Job 1
Title Hours per week Length of Employment

Job 1: Predominant Working Posture
Seated
Walking / Standing
Mixed
Job 1: Physical Demands of Role
Sedentary
Light / Medium Lifting
Heavy / Very Heavy Lifting
Employment History: Job 2
Title Hours per week Length of Employment

Job 2: Predominant Working Posture
Seated
Walking / Standing
Mixed
Job 2: Physical Demands of Role
Sedentary
Light / Medium Lifting
Heavy / Very Heavy Lifting
Employment History: Job 3
Title Hours per week Length of Employment

Job 3: Predominant Working Posture
Seated
Walking / Standing
Mixed
Job 3: Physical Demands of Role
Sedentary
Light / Medium Lifting
Heavy / Very Heavy Lifting

Medical History
Cardiovascular
Have you had any diagnosed cardiovascular conditions in the past that have been resolved [i.e. including and not subject to high blood pressure, heart problems, stroke, peripheral disease].*

Yes

No
Are you currently diagnosed with any cardiovascular conditions [i.e. including and not subject to high blood pressure, heart problems, stroke].*

Yes

No
Has any member of your family [mother, father, brother, sister] had a heart attack or stroke before the age of 55 years*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Metabolic
Have you had any diagnosed metabolic conditions in the past that have been resolved [i.e. including and not subject to high cholesterol, diabetes, liver and kidney disease]*

Yes

No
Are you currently diagnosed with any metabolic conditions [i.e. including and not subject to high cholesterol, diabetes, liver and kidney disease].*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Neurological
Have you had any diagnosed neurological conditions in the past that have been resolved [i.e. including and not subject to epilepsy, multiple sclerosis, cerebral palsy, Alzheimer’s].*

Yes

No
Are you currently diagnosed with any neurological conditions [i.e. including and not subject to epilepsy, multiple sclerosis, cerebral palsy, Alzheimer’s].*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Psychological
Have you been diagnosed with any psychological condition[s] that have been resolved [i.e. including and not subject to depression, anxiety, post-traumatic stress disorder].*

Yes

No
Are you currently diagnosed with any psychological conditions [i.e. including and not subject to depression, anxiety, post-traumatic stress disorder].*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Endocrinological
Have you been diagnosed with any endocrinological condition [i.e. including and not subject to hyper-thyroid, hypo-thyroid, type 1 diabetes].*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Respiratory
Have you had any diagnosed respiratory condition in the past that have been resolved [i.e. including and not subject to asthma, chronic obstructive pulmonary disease].*

Yes

No
Are you currently diagnosed with any respiratory conditions [i.e. including and not subject to asthma, chronic obstructive pulmonary disease].*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Musculoskeletal
Have you been previously or currently diagnosed with the following injuries and/or conditions?
No
Strain
Sprain
Overuse
Other soft tissue injury (muscle, ligament, tendon)
Dislocation
Fracture
Arthritis (Osteo or Rheumatoid)
Osteoporosis
General Pain
If yes to any of the above, please describe including the treatment plan:
If yes to any of the above, please indicate the body part:
Head
Neck
Shoulder
Elbow
Arm/Hands
Back
Knees
Legs/feet
Do you have or have you had any pre-existing foot and/or ankle injuries?*

Yes

No
Have you ever had difficulties standing and/or walking for long periods (in excess of 45 mins)?*

Yes

No
Have you undergone or expect to undergo any surgical procedures to:
Head
Neck
Shoulder
Elbow
Arm/Hands
Back
Knees
Legs/feet
If yes to any of the above, please provide further detail:
Hearing / Vision
Have you been diagnosed with any vision impairment and require the use of glasses?*

Yes

No
Have you been diagnosed with any hearing impairment and required the use of aids?*

Yes

No
If yes, please describe including any current aids:

Please indicate if your vaccinations are up to date for:
Tetanus
Diptheria
Whooping Cough
Measles / Mumps
Chicken Pox
Hepatitis B
Fully Covid-19 Vaccinated
Do you consume alcohol on a frequent basis?*

Yes

No
If yes, how often do you consume alcohol?

Less than once per week

Once per week

Average 1-2 days per week

Average 3-4 days per week

Average 5-6 days
When you consume alcohol, how many standard drinks may you have?

1 - 2 standard drinks

3 - 4 standard drinks

5-8 standard drinks

>8 drinks
To the best of your knowledge, do you believe you may be pregnant?*

Yes

No
Do you frequently experience shortness of breath and/or abnormal chest pain during activities of daily living?*

Yes

No
Do you experience swelling in your lower limbs during activities of daily living?*

Yes

No
List any medications you are currently taking (prescription and over the counter)
Do you believe that any medication you are currently taking may impact your ability to complete the assessment and / or the applied for position?*

Yes

No

Not Applicable
If yes, please describe medication(s) and its effect(s)
You will be taking part in a pre-employment assessment that will be physically demanding. To the best of your knowledge do you have any medical condition(s) that may affect your ability to perform the assessments?*

Yes

No
To the best of your knowledge, do you have any medical condition(s) that may affect your ability to complete the applied for position as per the job task analysis?*

Yes

No

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Peha + Da Consent Form - WA

Step 1 of 4

Medical Questionnaire

Medical History

Cardiovascular

Metabolic

Neurological

Psychological

Endocrinological

Respiratory

Musculoskeletal

Hearing / Vision