Title Page
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Site conducted
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Conducted on
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Name
Information - Please complete all of the fields below
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Date of birth
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National Insurance Number
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Bank Name
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Bank Acc No
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Bank Sort Code
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Next of Kin Name
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Next of Kin Contact Details
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Relationship with Next of Kin
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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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Seen and authorised by
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 give details
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Has any previous occupation caused you health problems?
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Please give details
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Are you in receipt of a medical pension or other disability benefit?
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Please give details
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Have you ever had 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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22 Diabetes?
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23 Kidney trouble or urinary infection?
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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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Is your eyesight normal (with glasses/contact lenses if worn)?
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Is your hearing normal?
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Are there any medical reasons why you should not do shift work?
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Are you able to carry out physical work such as lifting, carrying, climbing ladders etc
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The Equality Act 2010 defines a person with a disability as “A physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.”
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Do you have a 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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Please sign to confirm the above is correct
