Thomas Cook - First time Cabin Crew Application

Appendix A Cabin Crew Initial Medical Assessment In Accordance With Part-Med Med.C.005

The information provided in this questionnaire will be treated confidentially and will not be passed on to your employer. The employer will only be advised of the outcome of the assessment in terms of ‘fit’ or ‘not fit’.

Please note that incorrect or incomplete forms will not be processed and you will be asked to resubmit the questionnaire.


Title
First Name
Surname
Previous Name
Date of Birth
Gender
Email Address
Telephone Number
Place of Birth
This MUST be as shown on your passport.
Nationality
This MUST be as shown on your passport.
When is your booked appointment scheduled?
Your Address
Please include the postcode.
Your GPs Address
Please include the postcode.
Your GPs Name
Your GPs Telephone Number
Question 1. Alcohol

Do you drink alcohol?

Please provide details.
Go to Question 2.
Alcohol Units

How many units of alcohol do you drink per week?

Question 2. Tobacco

Do you smoke?

Please provide details.
Go to Question 3.
When did you stop smoking?

If you have smoked in the past but have since quit, please let us know when you stopped smoking.

Question 3. Medication

Do you currently use any medication?

Please provide details.
Please go to Question 4.
Medication details

Please state the name of the medication, the dosage, the date you started taking it and why.

Question 4. Vision

Do you, or have you ever had, a problem with distant or close vision?

Please provide details.
Go to Question 5.
Vision details

If you answered Yes to question 4, please provide the details here:

Question 5. Glasses & lenses

Have you ever worn glasses or contact lenses?

Please provide details.
Go to Question 6.
Details

If you answered Yes to Question 5, please provide the details here:

Question 6. Eyes

Have you ever had eye disease or surgery?

Please provide details.
Go to Question 7.
Details

If you answered Yes to Question 6, please provide details here:

Question 7. Hayfever

Have you ever had hayfever?

Please provide details.
Go to Question 8.
Details

If you answered Yes to Question 7, please provide details here:

Question 8.

Do you have, or have you ever had, any allergies?

Please provide details.
Go to Question 9.
Details

If you answered Yes to Question 8, please provide details here:

Question 9.

Do you have, or have you ever had, any asthma or lung problems?

Please provide details.
Go to Question 10.
Details

If you answered Yes to Question 9, please provide details here:

Question 10.

Do you have, or have you ever had, any form of heart or vascular disease or stroke?

Please provide details.
Please answer Question 11.
Details

If you answered Yes to Question 10, please provide details here:

Question 11.

Do you have, or have you ever had, high blood pressure?

Please provide details.
Go to Question 12.
Details

If you answered Yes to Question 11, please provide details here:

Question 12.

Do you have, or have you ever had, kidney stone or blood in urine?

Please provide details.
Go to Question 13.
Details

If you answered Yes to Question 12, please provide details here:

Question 13.

Do you have, or have you ever had diabetes or a hormone disorder?

Please provide details.
Go to Question 14.
Details

If you answered Yes to Question 13, please provide details here:

Question 14.

Do you have, or have you ever had, stomach, liver or intestinal trouble?

Please provide details.
Go to Question 15.
Details

If you answered Yes to Question 14, please provide details here:

Question 15.

Do you have, or have you ever had, an ear disorder?

Please provide details.
Go to Question 16.
Details

If you answered Yes to Question 15, please provide details here:

Question 16.

Do you have, or have you ever had, a hearing problem?

Please provide details.
Go to question 17.
Details

If you answered Yes to Question 16, please provide details here:

Question 17.

Do you have, or have you ever had, a nose, throat or sinus disorder?

Please provide details.
Go to Question 18.
Details

If you answered Yes to Question 17, please provide details here:

Question 18.

Do you have, or have you ever had, speech difficulties?

Please provide details.
Go to Question 19.
Details

If you answered Yes to Question 18, please provide details here:

Question 19.

Do you have, or have you ever had, headaches or migraine?

Please provide details.
Go to Question 19.
Details

If you answered Yes to Question 19, please provide details here:

Question 20.

Do you have, or have you ever had, epilepsy or seizure?

Please provide details.
Go to Question 21.
Details

If you answered Yes to Question 20, please provide details here:

Question 21.

Do you have, or have you ever had, dizziness, episode of fainting or unconsciousness for any reason?

Please provide details.
Go to Question 22.
Details

If you answered Yes to Question 21, please provide details here:

Question 22.

Do you have, or have you ever had, neurological disorders?

Please provide details.
Go to Question 23.
Details

If you answered Yes to Question 22, please provide details here:

Question 23.

Do you have, or have you ever had, psychiatric or psychological trouble of any sort?

Please provide details.
Go to Question 24.
Details

If you answered Yes to Question 23, please provide details here:

Question 24.

Have you ever suffered from alcohol, drug or substance abuse?

Please provide details.
Go to Question 25.
Details

If you answered Yes to Question 24, please provide details here:

Question 25.

Have you ever attempted suicide?

Please provide details.
Go to Question 26.
Details

If you answered Yes to Question 25, please provide details here:

Question 26.

Do you have, or have you ever had, anaemia, sickle cell disease or other blood disorder?

Please provide details.
Go to Question 27.
Details

If you answered Yes to Question 26, please provide details here:

Question 27.

Do you have, or have you ever had, malaria or other tropical disease?

Please provide details.
Go to Question 28.
Details

If you answered Yes to Question 27, please provide details here:

Question 28.

Have you ever had a positive HIV test?

Please provide details.
Go to Question 29.
Details

If you answered Yes to Question 28, please provide details here:

Question 29.

Do you have or have, you ever had, an infectious disease?

Please provide details.
Go to Question 30.
Details

If you answered Yes to Question 29, please provide details here:

Question 30.

Have you ever had an admission to hospital?

Please provide details.
Go to Question 31.
Details

If you answered Yes to Question 30, please provide details here:

Question 31.

Do you have, or have you ever had, a skin disorder?

Please provide details.
Go to Question 32.
Details

If you answered Yes to Question 31, please provide details here:

Question 32.

Do you have arthritis, or a disorder affecting strength or movement?

Please provide details.
Go to Question 33.
Details

If you answered Yes to Question 32, please provide details here:

Question 33.

Do you have any other illness or injury not specified here?

Please provide details.
Go to Question 34.
Details

If you answered Yes to Question 33, please provide details here:

Question 34. Family History

Have your family had any of the following conditions:

Mark all that apply.

I hereby declare that I have carefully considered the statements made here and that to the best of my knowledge they are complete and correct and that I have not withheld any relevant information or made any misleading statement.