pre course health questionnaire for … · pre course health questionnaire for bds dentistry /...

University of Bristol Occupational Health Service

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Pre Course Health Questionnaire for BDS Dentistry / Gateway to Dentistry

CONFIDENTIAL

Introduction The University of Bristol’s Faculty of Health Sciences is responsible for determining the fitness to practise of their students and therefore protecting, promoting and maintaining the health and safety of the public. Applicants need a sufficient standard of physical and mental health to enter and remain in the dental profession. Therefore assessment of medical fitness forms a key element of your application process.

All candidates offered a place are required to complete and return the enclosed confidential declaration of health questionnaire. The questionnaire asks candidates to disclose specified medical conditions and to provide information on any disability/health condition that may require support whilst they are studying. The University of Bristol is committed to ensuring equality of opportunity for students with disabilities and health conditions. Most health conditions and impairments, even if substantial, should not impede you from being accepted for training and will not raise fitness to practise concerns. If you have a condition which would make it impossible for you to work safely with patients or to acquire the skills necessary to complete training, even with adjustments and support then you cannot be accepted onto the course. You should not assume that an impairment or health condition will prevent you being able to take up your offered place. The health and fitness requirements are defined in the GDC publication, ‘Preparing for Practice (revised 2015)’ available at www.gdc-uk.org.

Please complete the enclosed questionnaire and immunisation record and sign the declaration in section 4 and then arrange for your General Practitioner to complete Section 5. Please note that you will be responsible for any charges your GP may make.

Once you have completed all sections please return in a sealed envelope by 16 June 2018 to the Occupational Health Service, University of Bristol, 1-9 Old Park Hill, Bristol, BS2 8BB. Please keep a copy and ensure you pay the correct postage. Failure to return this on time will result in a delay in processing your application.

If you declare a disability or health condition which could affect you in your training, an Occupational Health Advisor will contact you for more information. The Faculty of Health Sciences will be informed of any disability or health condition that would affect your fitness to practise.

If you do not take up your place the form will be destroyed.

Additionally, clearance for serious communicable diseases is required, with blood testing for markers of current Hepatitis B, C and HIV infection. These tests need to be carried out by Spire Pathology Services; please see attached information. You must have attended for your blood tests on confirmation of your place at Bristol by 31/08/2017, at the very latest. Failure to complete this process within the given timescales will result in a delay in processing your application.

Occupational Health Service 1-9 Old Park Hill Bristol BS2 8BB [email protected]

https://www.gdc-uk.org/professionals/students-and-trainees/learning-outcomes

mailto:[email protected]


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CONFIDENTIAL

The information provided will be treated as confidential and seen only by the University of Bristol Occupational Health Service. Please complete using black ink.

Section 1: Personal Details

Title (Mr,Ms,Mrs,Miss,etc)

Family name

Given name(s)

Date of birth

Male / Female

Contact address

Postcode

Home telephone number

Mobile number

E-mail address

General Practitioner (Name/address and telephone number)

Section 2: Your Functional Capabilities

Do any of the following present you with difficulty? Yes No

a Mobility eg walking, running, using stairs

b Agility eg, bending, reaching up, kneeling down, maintaining balance

c Dexterity eg getting dressed, writing, using tools

d Physical exertion eg lifting, carrying, running

e Communication eg speech, hearing

f Vision eg visual impairment, colour blindness, tunnel vision

g Learning eg dyslexia, dyspraxia, dyscalculia, impaired concentration

If yes to any of the above, give details eg extent of disability or health condition, any support needs or adjustments required at your place of study or work.


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Section 3: Your Health

Please answer all of the following questions. If you answer yes, please give further details, continuing on a separate piece of paper if necessary.

1. Do you have any of the following? Yes No

a Chronic skin conditions? eg eczema, psoriasis

b Neurological disorder? eg epilepsy, fits or blackouts, multiple sclerosis

c Allergies? eg to latex, medicines, foods, animals

d Endocrine disease? eg diabetes

If yes to any of the above, give details eg extent of disability or health condition, any support needs or adjustments required at your place of study or work.

2. Have you ever been affected by? Yes No

a Sudden loss of consciousness? eg a fit or seizure

b Chronic fatigue syndrome? (or similar condition)

c An eating disorder? eg bulimia, anorexia nervosa, compulsive eating

d Drug or alcohol dependency problems?

e Mental health problems? eg anxiety, depression, schizophrenia, bipolar affective disorder, stress related illness, OCD or personality disorders

f Have you ever been treated by a psychiatrist, psychotherapist or counsellor?

If yes to any of the above, give details eg reason, when condition developed, how long it lasted, its effects on you, treatment, and outcome, adjustments required at your place of study or work.

3. Are you currently taking any regular medication or receiving any treatment? Please circle.

Yes No

If yes, give details

4. Do you have any disability or health condition not already mentioned for which you think that you may require support or adjustments during your education or training? Please circle.

Yes No

If yes, give details

5. What is your height?

metres 6. What is your weight?

kg


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Section 4: Declaration

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I understand that I may be contacted by a member of the Occupational Health Service for a more detailed assessment. I consent to the University of Bristol’s Faculty of Health Sciences being informed of any disability or medical condition that could require support or affect my fitness to practise. I also understand that I have a responsibility to inform the Faculty if this declaration of health changes before coming to University or throughout the duration of the course. I agree for the Occupational Health Service to use my mobile phone number to send me notifications, appointment reminders and passwords to encrypted documents sent via email (you can change your mind at any time by notifying us via email [email protected]).

Signed: _________________________________________ Date: ________________________

Section 5: Doctor’s Certificate

. Your patient has been offered a place to study at the University of Bristol. All prospective dental students need a sufficient standard of physical and mental health to enter and remain in the profession. Candidates are asked to complete and return the declaration of health questionnaire providing information to assess their fitness to practise. We are not asking you for your opinion about their competence to practise, as this will be assessed during the course. However, we do require applicants’ doctors to verify the health information provided by applicants on the basis of their knowledge of the patient.

Yes No

1. Are you the applicant’s usual doctor?

2. Are you a relative of the applicant?

3. Do you hold the applicant’s medical records?

4. According to your records and knowledge of the applicant, do the answers to sections 2 and 3 and the immunisation record appear correct? (please add any comments below)

5. Are you aware of any additional medical information which may be relevant to this application? (please add any comments below)

Details:

PLEASE NOTE. A medical examination is not required. Any fee required for completion of the form is the responsibility of the patient.

Doctor’s Signature _______________________

Doctors name___________________________

Date ___________________________________

Practice Stamp



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For University Occupational Health Service Use Only

Comments

Signed

Date


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Immunisation Record CONFIDENTIAL

Please complete this form and return with your pre-course health questionnaire.

Section 1: Course Details

Course Title and Code

Section 2: Personal Details


Family name

Given name(s)

Date of birth

Male / Female

Section 3: Immunisation History

Please add the dates of any immunisations in the relevant boxes below.

Vaccination received 1st Dose 2nd Dose 3rd Dose Booster Booster

Diphtheria, Tetanus & Polio (DTP)

Hepatitis B

Measles, Mumps & Rubella (MMR)

Tuberculosis (BCG vaccination)

Chickenpox (Varicella) Have you ever had chicken pox?

YES Date:

NO

Please note that all vaccinations that are required for the BDS Dentistry programme are given free of charge on arrival if vaccinations have not been obtained previously.

Section 4: Declaration

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Signed: ______________________________________ Date: ________________________


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Occupational Health Service

Immunisation information

Hepatitis B

All applicants should be vaccinated, using the following vaccination schedule for hepatitis B vaccine at 0, 1 and 6 months, unless known to be immune through previous vaccination or infection. Please give dates of vaccination, it is appreciated that unless previously vaccinated, the course is likely to be incomplete when returning this form. Response to vaccine should be checked by an antibody test (anti-HBs) taken eight weeks after the third injection. A level of >100 m IU/ml is evidence of satisfactory immunity. Please record the date, result and attach a copy of the laboratory test if a blood test has been done.

Measles, Mumps and Rubella

All applicants should have a documented history of two doses of MMR vaccine or serological evidence of rubella and measles immunity. Please record the date, result and attach a copy of the laboratory test if a blood test has been done. A past history of the illness alone is not sufficient evidence of immunity.

Diphtheria, Tetanus and Polio (DTP)

All applicants should have a documented history of five doses of DTP vaccine. This is part of the childhood immunisation programme and should be completed by your General Practitioner. Please ensure all dates are included.

Tuberculosis

All applicants should have received a BCG vaccination for protection against tuberculosis. If you have not had this vaccination in childhood you may be able to obtain it from your GP. Please be aware that any incurred costs are your responsibility. For those students arriving from elsewhere, you will be assessed in line with our new TB policy. Currently there is a global shortage of the BCG vaccine (used for immunisation against TB). The UK contracted supplier has not been able to supply the BCG vaccine consistently and remaining stock has been prioritised by Public Health England (PHE) with vaccination for occupational risk reasons being the lowest priority. More details will be provided to you once you start the course.

Varicella Zoster (VZV) – Chickenpox

A history of infection with chickenpox or herpes zoster is adequate evidence of immunity if lived in temperate climates during childhood.1 If raised in tropical climates2 despite a history of chickenpox, VZV serological evidence is required. VZV IgG positive indicates adequate protection; VZV negative indicates the need for two doses of VZV vaccine. We will offer vaccination to seronegative students once they commence their training.

In accordance with national guidance additional screening tests will be undertaken by Occupational Health on commencement of the course.

1 Temperate regions are defined as United Kingdom, rest of Europe, North America, Antipodes, Middle East and Indian sub-continent

2 Tropical regions are defined as sub-Saharan Africa, South East Asia, Caribbean and Central America.


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Spire Blood tests confirmation CONFIDENTIAL

I have received the information regarding the Spire Blood Test Information and have made arrangements for the tests before I start the course. (Please tick)

Appointment Date: ___________ Appointment Time_______________

Spire Laboratory Address: _______________________________________________________

Telephone Number: __________________

Please email this confirmation to: [email protected]. Print Name: __________________________________ Date of Birth: ________________

Signed: ______________________________________ Date: ________________________



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Information for Dental students on screening for blood borne viruses

Training to be a dentist involves what are known as Exposure Prone Procedures (EPP). These are activities where, in the case of an accident, there is the potential for your blood or body fluids to come in contact with a patient. As a result, all potential dental/oral health sciences students are required to undergo screening for blood borne viruses (Hepatitis B and C, and HIV) prior to their place at the University of Bristol being confirmed. It should be noted that potential applicants who are found to be infectious carriers of hepatitis B, hepatitis C or HIV but who are successfully treated and appropriately monitored for their infection as defined in DoH guidance will then become eligible to perform EPPs and therefore to apply for admission to dental school. For your convenience, the Dental School has entered into a contract with Spire Pathology Services to undertake the tests. Spire Pathology Services have 20 locations throughout the UK, the locations can be found at www.spirehealthcare.com/spire-pathology-services/contact-us1/locations/. You are asked to arrange an appointment as soon as your place is confirmed in order to minimise any delay in the selection process. If your place is conditional on academic requirements, this should be for a date after your results are due, as the University will only pay for the tests when your place is confirmed on UCAS Track. The tests must be completed by 31 August. Please ensure you complete the enclosed form and take it together with this letter to your appointment. You will also need to take with you photographic evidence of your identity (eg passport/driving licence with photo ID).

PLEASE NOTE:

▪ The University of Bristol’s Faculty of Health Sciences will be responsible for the laboratory

charges for all applicants whose place has been confirmed on UCAS Track. The results of the tests will be sent from the laboratory confidentially to the University of Bristol Occupational Health Service. The Faculty of Health Sciences will be advised on your fitness to pursue the course. Your GP will not routinely be informed of your tests or results.

▪ In the case of a positive result you will be contacted personally by the Occupational Health

Service to discuss matters further. ▪ We recognise that undergoing tests for blood borne viruses may give rise to anxiety. You may

wish to have these tests prior to attending Spire at a confidential Genitourinary Medicine Clinic (particularly if you think you may have been at risk) and confidentially discuss any queries or concerns about HIV and sexual health in general.

▪ Tests performed elsewhere must be repeated in the UK, by an accredited laboratory,

holding full or provisional accreditation status. ▪ If you have any questions, queries or wish to discuss any concerns, please do not hesitate to

contact University of Bristol Occupational Health Service: [email protected].

http://www.spirehealthcare.com/spire-pathology-services/contact-us1/locations/

http://www.spirehealthcare.com/spire-pathology-services/contact-us1/locations/



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Dental Students

Please complete this form and take it with you to your appointment with Spire Pathology Services

(Do not forget your photographic ID – Passport/Drivers Licence with photo ID)

Screening for Blood Borne Viruses:

Hepatitis B (surface antigen), Hepatitis C antibodies; HIV antibodies


Family name

Given name(s)

Contact address

Postcode

Home telephone number

Mobile number

E-mail address

Date of birth

Male / Female

General Practitioner (Name/address and telephone number)

My preferred method of contact in the event of a positive test is? Call to landline

Call to mobile

Letter

In the event of being unable to contact you directly can we contact your GP?

Yes No

I consent to the tests as indicated Yes No

Signature


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Spire Manchester Hospital Russell Road

Whalley Range Manchester

M16 8AJ Dear Sir/Madam The person presenting you with this letter has an appointment for a venepuncture and is a dental student requiring certain pathology tests to be performed prior to admission onto their course. This testing is mandatory prior to admission to the university and Spire Hospitals’ have the national contract to provide this service. All that is required is for a blood sample to be taken, (a 5ml clotted sample), and all the paperwork with the client’s details, sent to the laboratory. They do not need to be registered nor should they be charged. The charge for the venepuncture is part of the overall vendor fee for the testing and will be re-distributed from the pathology department to the clinic or department. If you have any queries regarding this process please contact the laboratory manager. Yours faithfully C R Woodford National Pathology Manager


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Occupational Health Service Completing your health declaration form

This guidance sheet provides answers to many frequently asked questions on completing your health declaration form. Where do I send my completed form?

Occupational Health Service Safety and Health Services 1-9 Old Park Hill Bristol BS2 8BB

What do I do if I lose the form?

You can download the form from our website:

bristol.ac.uk/study/undergraduate/after-you-apply/after-accepting/questionnaires/

What if I am unable to complete the form by the due date due to being away on a gap year or for any other reason?

Please notify the Occupational Health Service of any expected delay: [email protected]

What if my GP is delaying completing his section?

We must have this section completed in order for the form to be assessed, please do not send it back until your GP has completed and signed section 5.

Do I need to send the form back by registered post?

You can return your form by registered post if you want confirmation of delivery, however if not standard post is sufficient. Please ensure you have paid the correct postage.

Do I need to keep a copy of the form?

Yes, in case your form does not arrive for any reason and for your own reference – take two copies if you can, one for home and the other to take with you to university.

http://www.bristol.ac.uk/study/undergraduate/after-you-apply/after-accepting/questionnaires/



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Questionnaire Checklist Before sending your questionnaire to us, please ensure you have:

Completed sections 1, 2 and 3 with your personal and health information;

Signed and dated the health declaration (section 4);

Had the Doctor’s Certificate (section 5) completed by your G.P. (this must include a

signature and practice stamp - your questionnaire cannot be assessed without the

certificate being fully completed);

Completed and signed the Immunisation Record, giving the dates of your

immunisations where appropriate;

Made at least one copy of the completed questionnaire for your records prior to

sending;

Used the correct postage (letters without the correct postage will not reach us, and

will be returned to you by the Post Office).


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