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Home
About Us
- Our Official Charity Partner
Meet the Team
Clients
Live Vacancies
- Register CV
Candidates
Refer a Friend Scheme
Care Packages for Brain and Spinal injury
Contact Us

Latex & Allergies

Your Health & Safety is paramount

At Libertatem Healthcare Group the health & safety of our workforce is extremely important to us. In order for us to safeguard your well being, please take 5 minutes to fill out the questionnaire below regarding latex & allergies. All information you provide will be treated in the strictest of confidence.

Name*
First Last
Date of Birth*
1. Do you have a history of any of the following?*
- Asthma - YES
- Asthma - No
- Hand Eczema - YES
- Hand Eczema - NO
- Hay Fever - YES
- Hay Fever - No
- Eczema anywhere else on your body - YES
- Eczema anywhere else on your body - No
Please select the condition and YES option if you have had any of the conditions below. If you haven't then select the condition and NO option.
2. Have you ever had surgery?*
- Yes
- No
If yes, then please give details
3. Have you had extensive dental work?*
- Yes
- No
4. Do you have any congenital abnormalities (e.g. spina bifida)?*
- Yes
- No
If yes, then please say the type
5. Do you have an allergy to any medicines, foods or other items?*
- Yes
- No
If yes then please state what
If you have answered yes to ANY of the questions this far then please continue to complete this form. If you have answered no to ALL of the questions this far, you may go the bottom of the form, sign date and submit it.
6. Have you ever reacted after handling or using the following items?
- Balloons - Yes
- Balloons - No
- Contraceptives - Yes
- Contraceptives - No
- Rubber Gloves - Yes
- Rubber Gloves - No
- Dental Blocks - Yes
- Dental Blocks - No
- Hot Water Bottle - Yes
- Hot Water Bottle - No
- Erasers - Yes
- Erasers - No
- Rubber Bands/Balls - Yes
- Rubber Bands/Balls - No
- Elastoplast or Elastic Bandages - YES
- Elastoplast or Elastic Bandages - No
- Elastic waistbands or underwear - Yes
- Elastic waistbands or underwear - No
- Other
Please select the item and YES option if you have had any of the items below. If you haven't then select the item and NO option.
Other - Please specify
7. Have you ever reacted after eating or handling the following?
- Apples - Yes
- Apples - No
- Avocados - YES
- Avocados - No
- Celery - YES
- Celery - No
- Bananas - YES
- Bananas - No
- Cherries - YES
- Cherries - No
- Chestnuts - YES
- Chestnuts - No
- Figs - YES
- Figs - No
- Grapes - Yes
- Grapes - No
- Kiwis - yes
- Kiwis - No
- Latex - Yes
- Latex - No
- Mangoes - Yes
- Mangoes - No
- Melons - Yes
- Melons - No
- Passion Fruit - Yes
- Passion Fruit - No
- Peaches - Yes
- Peaches - No
- Pistachios - YES
- Pistachios - NO
- Potatoes = Yes
- Potatoes - No
- Strawberries - Yes
- Strawberries - No
- Tomatoes - Yes
- Tomatoes - No
Please select the item and YES option if you have had any of the food/substance below. If you haven't then select the item and NO option.
If you have answered YES to any part of Questions 6 or 7, how long after contact or eating and what reaction do you usually expect to occur?
8. Specifically, have you ever experienced the following symptoms?
- Breathlessness - YES
- Breathlessness - No
- Skin Redness/ Rash - YES
- Skin Redness/ Rash - No
- Swelling of face , lips or tongue - YES
- Swelling of face , lips or tongue - No
- Congestion - YES
- Congestion - No
- Runny nose - YES
- Runny nose - No
- Urticaria (Hives) - YES
- Urticaria (Hives) - No
- Itchy/ watery eyes - YES
- Itchy/ watery eyes - No
- Itching - YES
- Itching - No
- Dizziness - Yes
- Dizziness - No
- Other
Please select the symptom and YES option if you have had any symptoms below. If you haven't then select the symptom and NO option.
Other, please specify
9. Have you ever suffered anaphylactic shock?
- Yes
- No
If so, please detail how many times and under what conditions?
Signature
Date

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CONTACT INFO

Libertatem
Head Office Libertatem Healthcare Group Trinity Court Molly Millars Lane, Wokingham RG41 2PY
01189 730006
info@libertatemhealthcare.co.uk

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