Title Page
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Select date
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Full Name
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Address
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DOB
Emergency Contact
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Emergency Contact - Name
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Emergency Contact - Telephone No
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Emergency Contact - Email / alternative Number
Medical Contact
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GP Surgery Name & Address
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GP Contact Telephone Number
Please read before completing this form
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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.
Questionnaire
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Are you disabled ?
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Have you had to give up any previous jobs for medical reasons ?
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Do you regularly take any medication or injections ?
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Do you have difficulty with your hearing
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Do you have difficulty with your speech ?
Are there any reasons why you cannot;
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Do strenuous work?
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Climb ladders ?
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Work from scaffolding ?
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Work at heights ?
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Do shift or night work ?
Do you have any physical problem preventing you from;
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Bending ?
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Lifting ?
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Carrying ?
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Kneeling
Give details of sickness during the last 12 months
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No of days
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Reasons for sickness during the last 12 months
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Are your presently receiving treatment from your doctor
Sight - Do you have difficulty with any of the following, with glasses or contact lenses if worn
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Reading a newspaper
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Reading a car number plate at 20 meters ?
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Seeing a television clearly ?
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Have you ever been told that you have abnormal colour vision ?
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Do you have any other eye problems ?
Have you ever been advised by a Doctor to avoid any of the following
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Driving a vehicle or machinery ?
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Dust or fumes ?
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Work with vibrating tools ?
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Manual Handling ?
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Work at Height ?
Have you ever been treated for any of the following
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Angina ( a pain or discomfort felt in your chest)
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Heart Trouble
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Raised blood pressure
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Asthma
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Persistent Cough
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Shortness of breath
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Tuberculosis (TB)
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Back Trouble
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Lumbago (pain in lower back)
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Sciatica
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Slipped Disc
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Arthritis
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Rheumatism
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Hernia
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Dermatitis
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Eczema
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Any other skin condition
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Epilepsy
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Recurring blackouts or fits
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Migraine
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Severe recurring headaches
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Anxiety
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Depression
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Any other nervous complaint
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Fainting attacks
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Dizziness
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Stomach ulcer
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Any other stomach problems ?
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Ear infections
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Other ear conditions
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Nose Bleeds
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Nasal trouble
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Sinus trouble
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Kidney trouble
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Urinary infection
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Varicose veins
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Diabetes
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Allergies including hay fever ** please note below if you carry an prescribed auto-injectable device
Continued
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Do you have any disabilities on relation to any of the questions answered ?
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If you do have disabilities please advise what reasonable adjustments have / should be made ?
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If there is any other health information which may affect your employment please give details
Declaration
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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.
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Signed
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Date