Information
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Document No.
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Please note this questionnaire is for the purposes of your employer and your employment with the company. The company named as Unico Clinics Ltd registered at The Bristol Office 2nd Floor, 5 High Street, Westbury On Trym, Bristol BS9 3BY.
Please read all questions carefully and answer correctly ensure you understand the statement at the end of the questionnaire -
Employee Picture
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Employee Name
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Clinic
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Position
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Date Of Birth DD/MM/YYYY . Age in Years
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Full Address
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Contact Number
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Name/Address/Tel No of General Practitioner
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Conducted on
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Prepared by
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Location
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Have you suffered from any of the following? Please provide details
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Any Skin Disease(s)
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Please provide further details
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Discharge or Infection of Ears
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Please provide further details
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Hearing Defect
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Please provide further details
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Asthma
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Please provide further details
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Hay Fever
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Please provide further details
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Allergies, Including Sensitivity To Antibiotics or other drugs
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Please provide further details
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Recurrent Sore Throats
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Please provide further details
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Sinusitis
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Please provide further details
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Bronchitis or any for of Lung Disease
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Please provide further details
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Pneumonia
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Please provide further details
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Tuberculosis
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Please provide further details
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Heart Disease
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Please provide further details
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High Blood Pressure
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Please provide further details
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Migraines or Headaches Requiring time of work or School
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Please provide further details
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Fits
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Please provide further details
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Blackouts
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Please provide further details
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Epilepsy
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Please provide further details
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Depression
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Please provide further details
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Nervous Breakdown
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Please provide further details
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Mental Illness
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Please provide further details
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Psychiatric Treatment
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Please provide further details
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Anorexia
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Please provide further details
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Are you Pregnant
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Please provide further details
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Backache or sciatica
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Please provide further details
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Rupture, Varicose Veins
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Please provide further details
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Foot Aliments
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Please provide further details
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Indigestion or stomach pain requiring time of work
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Please provide further details
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Kidney Problems
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Please provide further details
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Bladder Infection
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Please provide further details
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Eye Disease
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Please provide further details
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Contact Lenses
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Please provide further details
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Diabetes
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Please provide further details
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Aids, HIV or Hepatitis
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Please provide further details
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Serious Injury or Operation
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Please provide further details
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Admitted to Hospital
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Please provide further details
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Do you suffer from any disability or defect or illness Not Included Above
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Please provide further details
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Have you ever suffered any injury at work
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Please provide further details
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Have you taken days of work or school for illness over the past two years
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Please provide further details
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Are you receiving Injections, pills, tablets, or medicines from a doctor.
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Please provide further details
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Have you received statutory sick pay in the last 12 weeks
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Please provide further details
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Do you drink alcohol and if YES please inform how many units per week
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Do you smoke and if YES please inform how many per week
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What is your height
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What is your weight
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When were you last Immunised for Tetanus
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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
