Health questionnaire

Health Questionnaire
Name*
Date Of Birth

DayMonthYear
Date
If the answer is yes to any of the questions on this form, please give full details in the space provided of the dates, duration and outcome of the illness or condition. If we have any concerns about your fitness for work, employment will be subject to satisfactory medical reports.
Tuberculosis, asthma, bronchitis or chest problems?*

YesNo
Additional Comments*

Chest pain, heart condition or raised blood pressure?*

YesNo
Additional Comments*

Blackouts, fits or attacks of giddiness?*

YesNo
Additional Comments*

Depression, mental illness or nervous breakdown?*

YesNo
Additional Comments*

Rheumatism or arthritis?*

YesNo
Additional Comments*

Back trouble?*

YesNo
Additional Comments*

Typhoid, paratyphoid or other infectious disease?*

YesNo
Additional Comments*

Digestive or bowel disease?*

YesNo
Additional Comments*

Diabetes, thyroid or other gland trouble?*

YesNo
Additional Comments*

Bladder or kidney trouble?*

YesNo
Additional Comments*

Dermatitis or skin trouble?*

YesNo
Additional Comments*

Varicose veins?*

YesNo
Additional Comments*

Vision or Hearing problems?*

YesNo
Additional Comments*

Any other accident, operation or illness?*

YesNo
Additional Comments*

Have you any reason to believe you may be infected with any communicable disease (example COVID 19)*

YesNo
Additional Comments*

Any other current or recent medical condition or treatment which might affect your attendance or performance at work?*

YesNo
Additional Comments*

Do you intend to work night duties on a regular basis?*

YesNo
Additional Comments*

Any illness or medical condition that prevented you from attending work on your normal duties or activities for more than one week during the past year?*

YesNo
Additional Comments*

Any physical or mental impairment which has a substantial and long term effect on your ability to carry out day to day activities? If yes, please specify any special adjustments required in relation to work.*

YesNo
Additional Comments*

Do you smoke?*

YesNo
Additional Comments*

How many units of alcohol do you drink per week?*
(1 unit = 1/2 pint beer = 1 glass wine = 1 single whisky)

Any additional comments
Signature*

Clear
Should be Empty: