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

Name*
First Last
Email*
Date of Birth*
Gender*
- Male
- Female
- Prefer Not to Answer
Weight*
Height*
General Function Information
Provide details of your general physical capacity.
Suffer / suffered from any types of allergies or respiratory conditions?*
- Yes
- No
Experienced any pain with lifting or carrying weights, or performing any other body movements?*
- Yes
- No
Require any specialized personal equipment to perform work related tasks safely?*
- Yes
- No
Have any muscular , tendon or skeletal conditions (ie – spinal disc issues, carpal tunnel, tennis elbow, repetitive strains, etc)*
- Yes
- No
Ever lodged any type of compensation claim for any type of injury or illness?*
- Yes
- No
Medical Condition Information
Medical Conditions*
Provide details of your most significant physical or psychological medical conditions. If you don't have anything to declare write "NIL".
Condition Restrictions For How Long
Medications*
Provide details of your most significant physical or psychological medical conditions. If you don't have anything to declare write "NIL".
Name of Drug Dosage Amount Reason for Dosage (Associated Condition)
Injury History*
Record the details of your most significant injuries. If you don't have anything to declare write "NIL".
Injury Detail Residual / Current Effects Injury Year
Last medical checkup / GP visit*
Please provide details of your last medical check / GP examination. This can include a medical (rail, coal board etc) or a general checkup.
GP / Clinic Details of the visit (reason, diagnosis) Approx date of the visit
Functional Information
If you suffer from any of the below conditions please tick the box beside it.
- Vision
- Working at heights
- Walking / standing for extended periods
- Substance intolerance
- Skin disorders
- Lifting, carrying, or moving weights
- Blood-borne diseases or viruses
- Repetitive movements
- Bending / twisting / turning
- RIS / Carpal tunnel / Tennis elbow
- Shortness of breath
- Pain disorders (chest, hands, arms, etc)
- Spinal pain (neck / back)
- Stress or anxiety
- Abdominal disorders (hernia)
- Use of shoulders, arms, wrists, hands, or fingers
- Use of knees, ankles, feet, or toes
- Anything else not stated
Do you have problems with performing the following activities:
- Working in confined spaces
- Using chemicals
- Operating machinery or hand tools
- Working in hot conditions
- Working prolonged shifts (10+ hours)
- Underground work
- Flying (domestic FIFO)
- Working in remote locations
- Pushing, pulling, or moving objects
Please provide further details of any boxes ticked above.
Candidate Declaration of Understanding and Consent*
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.
- Yes
Consent to Consult and Obtain Medical / WorkCover Information*
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.
- Yes
Workforce Express Privacy Statement*
I have read and agree to the Workforce Express Privacy statement.
- Yes
Privacy Statement

Quick links:

Name of Drug	Dosage Amount	Reason for Dosage (Associated Condition)

Condition	Restrictions	For How Long

Injury Detail	Residual / Current Effects	Injury Year

Functional Capabilities

General Function Information

Medical Condition Information

Functional Information