Audit

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

Any Skin Disease(s)

Please provide further details

Discharge or Infection of Ears

Please provide further details

Hearing Defect

Please provide further details

Asthma

Please provide further details

Hay Fever

Please provide further details

Allergies, Including Sensitivity To Antibiotics or other drugs

Please provide further details

Recurrent Sore Throats

Please provide further details

Sinusitis

Please provide further details

Bronchitis or any for of Lung Disease

Please provide further details

Pneumonia

Please provide further details

Tuberculosis

Please provide further details

Heart Disease

Please provide further details

High Blood Pressure

Please provide further details

Migraines or Headaches Requiring time of work or School

Please provide further details

Fits

Please provide further details

Blackouts

Please provide further details

Epilepsy

Please provide further details

Depression

Please provide further details

Nervous Breakdown

Please provide further details

Mental Illness

Please provide further details

Psychiatric Treatment

Please provide further details

Anorexia

Please provide further details

Are you Pregnant

Please provide further details

Backache or sciatica

Please provide further details

Rupture, Varicose Veins

Please provide further details

Foot Aliments

Please provide further details

Indigestion or stomach pain requiring time of work

Please provide further details

Kidney Problems

Please provide further details

Bladder Infection

Please provide further details

Eye Disease

Please provide further details

Contact Lenses

Please provide further details

Diabetes

Please provide further details

Aids, HIV or Hepatitis

Please provide further details

Serious Injury or Operation

Please provide further details

Admitted to Hospital

Please provide further details

Do you suffer from any disability or defect or illness Not Included Above

Please provide further details

Have you ever suffered any injury at work

Please provide further details

Have you taken days of work or school for illness over the past two years

Please provide further details

Are you receiving Injections, pills, tablets, or medicines from a doctor.

Please provide further details

Have you received statutory sick pay in the last 12 weeks

Please provide further details

Do you drink alcohol and if YES please inform how many units per week

On a scale how many units per week

Do you smoke and if YES please inform how many per week

On a scale how many cigarettes per week

What is your height

What is your weight

When were you last Immunised for Tetanus

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.