Occupational Health Questionnaire Template

1. What is your name?

The answer should be a text input.

2. What is your age?

The answer should be a text input.

3. What is your gender?

The answer should be a text input.

4. What is your occupation?

The answer should be a text input.

5. How long have you been in this occupation?

The answer should be a text input.

6. Do you smoke?

The answer should be a single choice:

1. Yes, daily
2. Yes, occasionally
3. No

7. Do you drink alcohol?

The answer should be a single choice:

1. Yes, daily
2. Yes, occasionally
3. No

8. Do you have any allergies?

The answer should be a single choice:

1. Yes
2. No

9. Do you have any chronic conditions?

The answer should be a single choice:

1. Yes
2. No

10. Do you have any physical limitations that could impact your ability to perform your job?

The answer should be a single choice:

1. Yes
2. No

11. Have you experienced any recent illnesses or injuries?

The answer should be a single choice:

1. Yes
2. No

12. Do you feel safe in your workplace?

The answer should be a single choice:

1. Yes
2. No

13. Are you exposed to any harmful chemicals or substances in your workplace?

The answer should be a single choice:

1. Yes
2. No

14. Are you required to wear protective gear or clothing in your workplace?

The answer should be a single choice:

1. Yes
2. No

15. Do you experience any discomfort or pain related to your work environment?

The answer should be a single choice:

1. Yes
2. No

16. Are you satisfied with the lighting in your workplace?

The answer should be a single choice:

1. Yes
2. No