OFFICIAL MEDICAL- once completed

OTC Candidate Online Medical Questionnaire

Please answer the following questions openly and honestly- any queries or concerns
with the questionnaire should be directed to a member of staff- please note that any
specific clinical questions must be directed to a member of the medical staff. Additionally,
only include instances that have been recorded in your official medical history, or official
diagnoses.
Should you answer ‘Yes’ for any section please provide as much additional information as
possible in the box provided. Where applicable consider including the following information:

 Dates of injuries/illnesses and duration

 Were you hospitalised?
 Were you prescribed medication? If so what medication and for how long
 Treatment received? Still ongoing or recurring?

1. Personal Details

Name:
Phone Number:
Email:
NHS Number:

2. BMI

Height (cm) Weight (kg) BMI

3. Heart and Blood Vessels

Do you have or have you ever had a history of any of the following conditions?
Heart valve abnormalities. Cardiomyopathies. High blood pressure. Raynaud’s disease.
Previous deep vein thrombosis (DVT). Previous pulmonary embolus (PE).

Yes No

Additional information:

4. Eyes

Do you have or have you ever had a history of any of the following conditions?
Glaucoma. Keratoconus. Double vision. Visual field defects. Night blindness. Corneal grafts.
Recurrent corneal ulcers. Detached retina. Blindness in one eye. Squint surgery in the last six
months. Laser eye surgery in the last 12 months.

Yes No
Additional information:

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5. Ears, nose and throat

Do you have or have you ever had a history of any of the following conditions?
Ongoing: ear infection; grommets: perforated eardrum: nasal polyps whether treated or not.
Meniere’s disease. Deafness requiring hearing aids or cochlear implants. Obstructive sleep
apnoea/hypopnoea syndrome.

Yes No
Additional information:

6. Lungs and breathing

Do you have or have you ever had a history of any of the following conditions?
Asthma in the last four years. Bronchiectasis. Cystic fibrosis.

Yes No
Additional information:

7. Gut and diet

Do you have or have you ever had a history of any of the following conditions?
Untreated hernia. Crohn’s disease. Ulcerative colitis. Hirschsprung’s disease. Loss of spleen.
Coeliac disease (gluten sensitivity). Lactose intolerance. Requirement for specific dietary
restrictions, including any food allergies or intolerances. Two or more surgical treatments for a
pilonidal sinus. Any surgery for a hiatus hernia. Any surgery for an intestinal pouch. Weight
loss surgery (gastric bypass/band).

Yes No
Additional information:

8. Kidneys

Do you have or have you ever had a history of any of the following conditions?
Urinary incontinence. Nocturnal enuresis (bed-wetting) in the last two years. Polycystic kidney
disease. Kidney stones. Donation of a kidney in the last six months.

Yes No
Additional information:

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9. Brain and nerves

Do you have or have you ever had a history of any of the following conditions?
Ongoing epilepsy. More than one seizure (fit) after sixth birthday. Single seizure (fit) in the last
10 years. Multiple sclerosis. Hydrocephalus (with or without shunt). Migraine in the last two
years. Previous head injury resulting in ongoing intellectual (thinking), mental health or
brain/nerve problems. Previous brain surgery. Recurring faints or unexplained loss of
consciousness. Tourette syndrome.

Yes No
Additional information:

10. Glands

Do you have or have you ever had a history of any of the following conditions?
Diabetes. Adrenal disorders. Pituitary disorders.

Yes No
Additional information:
11. Skin

Do you have or have you ever had a history of any of the following conditions?
Ongoing psoriasis affecting a area of skin equivalent in size to the front of the forearm. Ongoing
severe acne requiring specialist care affecting the face, neck, shoulder, chest, back. Contact
dermatitis/eczema (where the skin becomes inflamed when it is in contact with certain
substances) now or in the past. Allergic dermatitis/eczema (where skin becomes inflamed but
the cause is unknown) in the last three years.

Yes No
Additional information:
12. Bones and joints

Do you have or have you ever had a history of any of the following conditions?
Club foot. Hammer toe. Complete loss of either big toe. Complete loss of either thumb. Loss of
a limb. Knee pain when exercising in the last year. Any joint replacements. Ongoing arthritis
(joint inflammation) of any cause. Osgood-Schlatter disease within the last two years. Any
fracture that has only fully healed in the last six months. Spine: any previous fracture, disc
surgery in the last two years, any other spine surgery. Shoulder dislocation: a single episode in
the last year, two or more episodes in the same shoulder, more than one shoulder stabilisation
operations on the same shoulder. Back pain: a single episode lasting more than six weeks,
three or more episodes lasting less than 48 hours (with no sciatica and no requirement to seek
medical attention) in the last 12 months.

Yes No

Additional information:

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13. Mental health

Do you have or have you ever had a history of any of the following conditions?
Ongoing mental health issues. Alcohol dependence. Drug or substance dependence in the last
four years, Manic disorder. Bipolar affective disorder. One episode of depression lasing more
than 2 months or three or more separate episodes of depression of any length. More than two
episodes of panic or generalised anxiety disorder. Psychosis. Schizophrenia. Obsessive
compulsive disorder (OCD). Autism. Personality disorder. Two or more episodes of deliberate
self harm of any type. Post-traumatic stress disorder (PTSD). Attention deficit hyperactivity
disorder (ADHD), unless you have been symptom free and have not needed treatment for the
last three years. Eating disorders including anorexia nervosa and bulimia nervosa.

Yes No
Additional information:

14. Cancer

Do you have or have you ever had a history of any of the following conditions?
Ongoing cancer or treated cancer under hospital or specialist follow up.

Yes No
Additional information:

15. Allergies

Do you have or have you ever had a history of any of the following conditions?
Severe allergic reactions and/or anaphylaxis. Latex allergy. Vaccine allergy (including tetanus
allergy).

Yes No
Additional information:

16. Infections

Do you have or have you ever had a history of any of the following conditions?
Ongoing tuberculosis (TB). Human Immunodeficiency Virus (HIV). Current acute or chronic
hepatitis. Carrier of Hepatitis B or C viruses.

Yes No

Additional information:

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17. Other

Do you have or have you ever had a history of any of the following conditions?
Have received a transplanted organ. Known carrier of Huntington’s disease, malignant
hyperthermia or neurofibromatosis. Ongoing pelvic inflammatory disease (PID). Ongoing
endometriosis.

Yes No

Additional information:

18. Supplementary Asthma

Do you have or have you ever had a history of any of the following conditions?
If you have had asthma at any stage of your life, including during childhood, but you have been
completely symptom free and off all asthma treatment within the last four years tick YES.

If YES, a history of asthma of more than four years ago may meet the medical standards for
entry. To help us assess your fitness you may be sent (a) a lungs and breathing questionnaire
(b) a peak flow rate meter and (c) a 28-day peak flow rate diary.

Yes No
Additional information:

19. Dental
If you have significant problems with your mouth or teeth you may not be fit to enlist.
Applicants with a brace only:
 If you are still being treated, you must keep seeing your civilian orthodontist.
 You must not discharge yourself from the care of your orthodontist until told by a military
dentist.
 Fixed or removable retainer (used to hold the teeth into position after your braces are
taken off) will not stop you joining and must continue to be worn.
Do not stop any treatment or have braces removed to get fit for joining the Army.
Your dental health Provide details here
Since the age of 16y, have you needed
medication to make you drowsy (sedation) or
needed medication to put you to sleep (general Yes No
anaesthetic) or fillings or other routine
dentistry?
Have you ever refused to undergo dental
treatment because it involved having an Yes No
injection?
Are you waiting for or have you been told to
have treatment in a hospital oral surgery Yes No
department?

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Do you have any mouth or teeth problems or

Yes No
treatment planned?
Do you have a dental brace in place? If YES,
what date is the course of treatment due to be Yes No
completed?
20. Eyesight
It is important to have good eyesight, although visual correction, such as spectacle of
contact lenses (within certain limits), is allowed for most Army jobs.
Your eyesight Details of any eyesight related
problems
Do you currently wear, or have you ever
Yes No
worn spectacles or contact lenses?
Have you ever had a squint or lazy eye? Yes No
Have you had any eye operations for a
squint or to correct your vision (for Yes No
example laser eye surgery)
Do you have any sight problems or any
injuries in either eye (other than needing Yes No
glasses)?
Do you currently have or have you had
Yes No
any other eye problem?
If you have answered YES to any of these questions, then you must ask your optometrist to
complete section ‘Optometrist’s Report’. (last page of this form)
Has a copy of the ‘Optometrist’s Report’
been filled in? Yes No
*If you wear glasses please print the ‘Optometrist’s Report’ on page 7 of this form and take it to your
opticians to be completed. Once completed scan the form into your computer then attach it to the
same email as this completed from. Also note, as a student you are entitled to free eye tests and
optical vouchers on the NHS, please see the link for further details:
https://www.nhs.uk/NHSEngland/Healthcosts/Pages/Eyecarecosts.aspx. Please also see the
following link for details on free dental care:
https://www.nhs.uk/NHSEngland/Healthcosts/Pages/Dentalcosts.aspx.

21. GP Details
Please be aware that you can only be registered to one GP at a time, registering with
another GP during this application process will cause delays.

Home GP details:
Practice/surgery name:
GP Name:
Address:

Phone Number:
Email:
How long have you been
registered with the practice?
University GP details (if applicable):
Practice/surgery name:
GP Name:
Address:

Phone Number:
Email:
How long have you been

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registered with the practice?

OPTOMETRIST’S
Which are you currently REPORT
Home University
registered with?
To be completed by the optometrist ONLY if applicant answers YES to section 20
The candidate has applied to join the Army and has answered YES to a question in section 20. An optometrist’s report based
upon an examination within the last 12 months is required as part of the screening process whereby the Army seeks to
exclude applicants with certain visual conditions. The application cannot be taken any further until this report is provided.
Please examine the candidate (if not seen in the last 12 months) and record your findings and answers to the questions.
Once complete p lease return to the applicant.

Client Name:
The candidate’s distant visual acuity is to be tested using
t h e standard Snellen chart at a distance of six metres.
Different charts a r e t o b e u s e d f o r e a c h e y e , u n c o r r e c t e d
Date of visual assessment
a n d c o r r e c t e d u s i n g complete occlusion of the eye not being
tested. No errors in a line are allowed (i.e. 6/12 –1 is to be
recorded as 6/18).
If BCVA in either eye demonstrates a refractive error outside +/- 6.0D then the candidate falls below the entry standard. The only
exception being when 6/6 (E1) is achieved at +/- 6.0D but a BCVA of 6/5 or 6/4 is achievable with minimal additional correction ie up to
+/- 6.25D. In this situation clinical judgment should be applied but entry may be permissible

RIGHT EYE LEFT EYE

Visual acuity Visual acuity

Uncorrected Corrected Uncorrected Corrected

Refraction Refraction

Sph Cyl Axis Sph Cyl Axis

Please record any other significant history or findings (attach extra sheets if necessary)

1. Is your client’s visual acuity equal to or better than the minimum standard of corrected Snellen visual
acuity of 6/12 in the right eye and 6/36 in the left eye, with a maximum permissible refractive error of +6.00 to Yes No
-6.00 dioptres in any meridian*

2. Has your client had corneal refractive surgery other than the following procedures: Radial Keratotomy
(RK), Astigmatic Keratotomy (AK), Photorefractive Keratectomy (PRK), Laser Epithelial Keratomileusis Yes No
(LASEK), Laser in-situ Keratomileusis (LASIK), Intrastromal corneal rings/ segments (ICRs/ICSs)?

3. If your patient has a squint, has had squint correction or any other eye surgery/ procedure do they have
Yes No
diplopia or any other visual defect?

4. Does your client have any other general eye, lid, lacrimal apparatus, conjunctival, corneal, lens, uveal
Yes No
tract, retinal, scleral, optic nerve, visual field, ocular motility or lid disorder?

If YES to any question, please provide details

Optometrist's signature Branch stamp

Optometrist's name - please print

Optometrist's telephone number

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The spherical equivalent is the algebraic sum of the spherical component of refraction plus half of the cylindrical component of the
refraction. For example:

Spherical +4.00D with cylindrical +2.00D = (+4) + (2/2) = ESE 5.00

Spherical -7.00D with cylindrical +3.00D = (-7) + (3/2) = ESE -5.50

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