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*Name
*Phone Number
1.1 High Blood Pressure
Yes
No
1.2 Heart Check Up
Yes
No
1.3 Hernia
Yes
No
Doctors Comments Only
2.1 Serious Injury
Yes
No
2.2 Impact any usual duties
Yes
No
Examining Medical Officers Comments (Q 2.1 & 2.2)
PART C – Worker’s declaration (To be completed by the worker in the presence of the health professional after completing the questionnaire)
Signature of Worker
Signature of Doctor
Date
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