Title Page
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Employee Name
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Department
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Date Form Completed
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Date of Birth
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National Insurance Number
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Bank Account Details
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Account Number
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Sort Code
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Name on Bank Account
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Proof of Right to Work
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Documentation Shown
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Original Seen and Photograph is a True Likeness
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Documentation seen by
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Next of Kin Details
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Next of Kin Name
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Next of Kin No
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Relationship to Next of Kin
Medical Questionairre
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Have you ever had to give up a previous job for medical reasons?
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Please give details
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Have you been off work continuously for more than a month in the last five years?
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Please give details
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Do you regularly take tablets or medicine?
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Please tell us what and if it has any side effects that may impact your job
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Do you wear Glasses or have any Eye Sight Problems?
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Please give details
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Do you have any Hearing issues?
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Please give details
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Do you have any Physical or Mental Impairment that could be classed as a Disability under the Equality Act 2010?
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Please give details
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Are there any reasons why you should not do shift work?
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Please explain
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Are you able to carry out physical work such as lifting, climbing ladders etc?
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Please explain
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Has any previous occupation caused you any Health Problems?
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Please give details
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Do you suffer from any of the following:
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1 Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness?
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2 Vertigo, dizziness, giddiness, problems with balance?
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3 Recurrent headache or migraine?
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4 Diseases of the nervous system e.g. neuritis, stroke, multiple sclerosis?
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5 Angina, heart disease or breathlessness?
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7 Raised or low blood pressure?
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9 Asthma, bronchitis, emphysema, pneumonia or any other lung disease?
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10 Jaundice or any form of hepatitis or other liver problem?
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14 Psoriasis, eczema, allergic skin rash or other skin disorder?
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16 Anxiety/depression, mental breakdown or stress related problems?
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20 Any operations or surgical procedures?
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21 Ear trouble or infected ear?
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24 Anxiety, depression or any other mental health condition?
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25 Peptic, gastric or duodenal ulcer?
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26 Any other serious illness not covered above?
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If you have answered yes to any of the above, please give further details to ensure the business can support you
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Please sign to confirm that all of the information in this form is accurate
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