F011 - Health Questionnaire

• Conducted on

  Date

• Full Name

• Address

• DOB

• Emergency Contact - Name

• Emergency Contact - Telephone No

• Emergency Contact - Email / alternative number

• GP Surgery Name & Address

• GP Contact Telephone Number

• This information is required in order that we can protect the health & safety of all employees, completion of this form will be regarded as your agreement to provide this information. The completed form will be stored in your individual personnel file. If you have any queries or concerns you should raise them with the person giving you the form before its completion. When completing the form you should answer all questions. If you answer ‘Yes’ to any answer you should provide more detail .The Company reserves the right to offer employment subject to a satisfactory medical examination. We cannot, however, contact your Doctor without your permission.

• Are you disabled ?

  Yes

  No

  N/A

• Have you had to give up any previous jobs for medical reasons ?

  Yes

  No

  N/A

• Do you regularly take any medication or injections ?

  Yes

  No

  N/A

• Do you have difficulty with your hearing

  Yes

  No

  N/A

• Do you have difficulty with your speech ?

  Yes

  No

  N/A

Are there any reasons why you cannot;

• Do strenuous work?

  Yes

  No

  N/A

• Climb ladders ?

  Yes

  No

  N/A

• Work from scaffolding ?

  Yes

  No

  N/A

• Work at heights ?

  Yes

  No

  N/A

• Do shift or night work ?

  Yes

  No

  N/A

Do you have any physical problem preventing you from;

• Bending ?

  Yes

  No

  N/A

• Lifting ?

  Yes

  No

  N/A

• Carrying ?

  Yes

  No

  N/A

• Kneeling

  Yes

  No

  N/A

Give details of sickness during the last 12 months

• No of days

• Reasons for sickness during the last 12 months

• Are your presently receiving treatment from your doctor

  Yes

  No

  N/A

Sight - Do you have difficulty with any of the following, with glasses or contact lenses if worn

• Reading a newspaper

  Yes

  No

  N/A

• Reading a car number plate at 20 meters ?

  Yes

  No

  N/A

• Seeing a television clearly ?

  Yes

  No

  N/A

• Have you ever been told that you have abnormal colour vision ?

  Yes

  No

  N/A

• Do you have any other eye problems ?

  Yes

  No

  N/A

Have you ever been advised by a Doctor to avoid any of the following

• Driving a vehicle or machinery ?

  Yes

  No

  N/A

• Dust or fumes ?

  Yes

  No

  N/A

• Work with vibrating tools ?

  Yes

  No

  N/A

• Manual Handling ?

  Yes

  No

  N/A

• Work at Height ?

  Yes

  No

  N/A

Have you ever been treated for any of the following

• Angina ( a pain or discomfort felt in your chest)

  Yes

  No

  N/A

• Heart Trouble

  Yes

  No

  N/A

• Raised blood pressure

  Yes

  No

  N/A

• Asthma

  Yes

  No

  N/A

• Persistent Cough

  Yes

  No

  N/A

• Shortness of breath

  Yes

  No

  N/A

• Tuberculosis (TB)

  Yes

  No

  N/A

• Back Trouble

  Yes

  No

  N/A

• Lumbago (pain in lower back)

  Yes

  No

  N/A

• Sciatica

  Yes

  No

  N/A

• Slipped Disc

  Yes

  No

  N/A

• Arthritis

  Yes

  No

  N/A

• Rheumatism

  Yes

  No

  N/A

• Hernia

  Yes

  No

  N/A

• Dermatitis

  Yes

  No

  N/A

• Eczema

  Yes

  No

  N/A

• Any other skin condition

  Yes

  No

  N/A

• Epilepsy

  Yes

  No

  N/A

• Recurring blackouts or fits

  Yes

  No

  N/A

• Migraine

  Yes

  No

  N/A

• Severe recurring headaches

  Yes

  No

  N/A

• Anxiety

  Yes

  No

  N/A

• Depression

  Yes

  No

  N/A

• Any other nervous complaint

  Yes

  No

  N/A

• Fainting attacks

  Yes

  No

  N/A

• Dizziness

  Yes

  No

  N/A

• Stomach ulcer

  Yes

  No

  N/A

• Any other stomach problems ?

  Yes

  No

  N/A

• Ear infections

  Yes

  No

  N/A

• Other ear conditions

  Yes

  No

  N/A

• Nose Bleeds

  Yes

  No

  N/A

• Nasal trouble

  Yes

  No

  N/A

• Sinus trouble

  Yes

  No

  N/A

• Kidney trouble

  Yes

  No

  N/A

• Urinary infection

  Yes

  No

  N/A

• Varicose veins

  Yes

  No

  N/A

• Diabetes

  Yes

  No

  N/A

• Allergies including hay fever ** please note below if you carry an prescribed auto-injectable device

  Yes

  No

  N/A

Continued

• Do you have any disabilities on relation to any of the questions answered ?

  Yes

  No

  N/A

• If you do have disabilities please advise what reasonable adjustments have / should be made ?

  Yes

  No

  N/A

• If there is any other health information which may affect your employment please give details

• PLEASE ENSURE YOU HAVE READ IN FULL & SIGN THIS SECTION AFTER YOU HAVE COMPLETED ALL PARTS OF THE FORM. If you have answered ‘Yes’ to any of the questions above, then we need to understand any risk associated with these conditions we will ask you to complete a further form to identify in full, any difficulties that you feel may require support and give complete details of any symptoms and the effect these have on your performance if any. After reviewing this information, you may be asked to obtain confirmation of your fitness to work from your GP or complete a consultation with an Occupational Health Professional. It is our obligation to ensure any health issues do not affect your ability to work, have further impact on your health, your safety or the safety of others. You are obliged to make us aware of any changes to your health which may impact on your ability to carry out your role either prior to or during the course of your employment, this includes change in medication. I certify to the best of my knowledge that the information given on this form is correct.

• Signed

  Sign

• Date

  Date