Title Page
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The Hub, Nathan Way
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Prepared by
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Location
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Medical Questionnaire
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(New Employees)
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The purpose of this questionnaire is to assist the company in complying with the requirements of employment, health & safety and food safety legislation. In accordance with the Data Protection Act 1998, the information given will remain confidential within the company
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Position applied for:
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Name:
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Date of Birth:
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Address:
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Please tick the boxes in answer to the following questions
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Have you ever suffered from enteric fever i.e. typhoid or paratyphoid?
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Have you or anyone in your household suffered from diarrhoea and/or vomiting within the last two weeks where symptoms persisted for 24 hours or more?
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Do you suffer from any skin problems affecting your hands, arms or face e.g. eczema, dermatitis, psoriasis, acne, septic spots or nail infections? If YES, please give details
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Are you currently suffering from or have you ever had recurrent infection of, or discharge from the ears, eyes, gums, nose or throat? If YES, please give details
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Do you have any allergies to food? If YES, please specify
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Have you suffered from asthma at any time in the last five years?
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Are you suffering from any medical condition for which you receive treatment or have regular specialist follow up? If YES, please give details
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Do you suffer from any recurrent chest problems e.g. bronchitis or sneezing?
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Do you suffer from fits, black outs or dizzy spells?
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Do you suffer from colour blindness?
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Have you had to leave or change a job for health reasons?
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If you have been outside the UK within the last 3 months please state where. Have you suffered any illness since?
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Please give details below for any of the questions answered YES
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I declare that the information I have given is true and complete to the best of my knowledge and belief (to be signed by the employee)
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Signed:
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Date:
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I confirm that this person is fit to work as a food handler (to be signed by management)
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Signed:
