Functional Capabilities

This form is to be used to declare any existing medical conditions that may affect or be aggravated by your employment with Workforce Express. This will be followed up with a physical capabilities analysis at one of our offices.

Functional Capabilities

  • General Function Information

    Provide details of your general physical capacity.
  • Medical Condition Information

  • Provide details of your most significant physical or psychological medical conditions. If you don't have anything to declare write "NIL".
    ConditionRestrictionsFor How Long 
    Add a new row
  • Provide details of your most significant physical or psychological medical conditions. If you don't have anything to declare write "NIL".
    Name of DrugDosage AmountReason for Dosage (Associated Condition) 
    Add a new row
  • Record the details of your most significant injuries. If you don't have anything to declare write "NIL".
    Injury DetailResidual / Current EffectsInjury Year 
    Add a new row
  • Please provide details of your last medical check / GP examination. This can include a medical (rail, coal board etc) or a general checkup.
    GP / ClinicDetails of the visit (reason, diagnosis)Approx date of the visit 
  • Functional Information

  • I acknowledge that the requested information on this form is required is to evaluate aspects my work health and safety, and I realize that any known omission or inaccuracy of the required information may put the health and safety of myself and others at risk. In the event of an incident occurring due to my known omission or inaccuracy of required information where it is proven as a contributor to an incident, I will not hold Workforce Express responsible for the consequences of requested information I knowingly withheld. I state that the voluntary information provided by myself upon this form is known to be true, correct & accurate at the time of participating in this process.
  • In addition to the above, I give my consent and permission for Workforce Express representatives to make contact and consult with my treating doctors, allied specialists and WorkCover Queensland with regards to any injury, diagnosis, rehabilitation program, medical condition or claim. I also give Workforce Express management permission to consult with WorkCover Queensland and directly obtain my personal information regarding my workers compensation claim, medical information, diagnostic reports, and associated treatments relevant to any of my compensation current claims. I understand that Workforce Express uses this information to effectively manage my claim, aide my recovery and where possible, mitigate any loss.
  • I have read and agree to the Workforce Express Privacy statement.
  • Privacy Statement