Audit

Have you suffered from any of the following? Please provide details

Do you suffer from epilepsy or fits?

Please provide further details

Have you ever suffered from blackouts, recurrent dizziness or any other condition which may cause sudden collapse or incapacity?

Please provide further details

Do you get discomfort or pain in the chest or shortness of breath on exercise, e.g. climbing a flight of stairs?

Please provide further details

Are you currently taking any medication (prescribed or otherwise) that may affect to carry out your duties safely?

Please provide further details

Do you currently have, or previously had any injuries or illness or conditions that may affect your ability to carry out your duties safely?

Please provide further details

If required, may we contact your GP in relation to medical records?

Please provide further details

If yes to previous question, please provide your GP's name and practice address:-

STATEMENT

I the employee named below understand and acknowledge that should I knowingly make a false statement regarding my medical history in answering the above questions, or should I conceal wilfully any material fact. I will if engaged, be liable to have my contract terminated. In the the event of any health queries I consent to my general practitioner supplying information to company.

Employee Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.