Pre Employment Health Questionnaire

Step 1 of 3

33%

PRIVATE AND CONFIDENTIAL

* indicated fields must be completed

Position Applied For(Required)

Name(Required)

Title First Name Last Name

Date of Birth(Required)

DD slash MM slash YYYY

Place of Birth(Required)

Age(Required)

Nationality(Required)

National Insurance (NI) No(Required)

Telephone Or Mobile Number(Required)

General Practitional

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

All candidates are required to complete the following questionnaire. All information will be treated privately and confidentially. All candidates are asked to answer each question by placing a tick in the relevant box. Should you answer Yes for any question, please give full details in the space provided on the next page.

Have you suffered or are you suffering from any of the following:

Any skin disease (including dermatitis and eczema)?(Required)

Yes

Discharge or disinfection of the ear or hearing defect?(Required)

Yes

Asthma or hay fever or sufficient severity to require time off work?(Required)

Yes

Any allergies (including sensitivity to antibiotics or other drugs)?(Required)

Yes

Discharge from the nose, recurrent sore throat or sinusitis?(Required)

Yes

Bronchitis or pneumonia?(Required)

Yes

Tuberculosis?(Required)

Yes

Recurrent diarrhoea, vomiting or dysentery?(Required)

Yes

Typhoid, paratyphoid, hepatitis, entities, enteric fever?(Required)

Yes

Recurrent boils or septic infections?(Required)

Yes

Have you visited the dentist in the last 12 months?(Required)

Yes

Have you ever suffered from high blood pressure?(Required)

Yes

Have you ever been diagnosed as suffering from any type heart disease?(Required)

Yes

Do you suffer from persistent headaches or migraine?(Required)

Yes

Depression, nervous breakdown or mental illness, psychiatric treatment?(Required)

Yes

Arthritis, rheumatism, back problems or sciatica?(Required)

Yes

Are you aware of any reason why you cannot lift objects?(Required)

Yes

Rupture, varicose veins or foot ailments?(Required)

Yes

Indigestion or stomach pains?(Required)

Yes

Kidney infection?(Required)

Yes

Bladder infection?(Required)

Yes

Eye disease, injury or significant defects of vision not corrected by spectacles?(Required)

Yes

Date of last eye test

DD slash MM slash YYYY

Diabetes?(Required)

Yes

Have you ever been admitted into hospital?(Required)

Yes

Have you ever had to stop work for more than one month for medical reasons?(Required)

Yes

Do you have any special needs or disability?(Required)

Yes

Are you currently under medication prescribed by your GP?(Required)

Yes

If you have answered YES to any of the questions, please provide details below: – Stating with the relevant question number

I understand and acknowledge that should I knowingly make a false statement regarding my medical history either in answering the above questions or to any medical examiner, or should I wilfully conceal any material fact, I will if engaged be liable to have my contract terminated. In the event of any health queries I consent to my general practitioner supplying relevant information to the company medical advisor. I confirm that there is nothing in my current circumstance that would be detrimental to me working either on a shift roaster basis throughout the night.

Applicant’s Name(Required)

Application Date of Completion(Required)

Day

Month

Year

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Pre-Employment Health Questionnaire Form.

PRIVATE AND CONFIDENTIAL