Igloo in partnership with...
Please complete the questionnaire below. The information is required with your interests in mind. The information you have given may be referred to the Company’s Occupational Health provider, so that a pre-employment medical examination can be conducted. Please note, this information will be treated as confidential.
Job Title:
Department:
Personal Information
Name:
Address:
Mobile:
Telephone:
Date of Birth:
National Insurance Number:
Would you object to being contacted on your work number (if necessary)?
Name & Address of your General Practitioner:
Telephone:
Medical History
| Have you previously... |
Yes/No |
Please elaborate if the answer is YES: |
| Had an operation? |
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| Been seriously injured? |
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| Received in-patient treatment for a physical or mental condition? |
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| Been refused or dismissed from employment for health reasons? |
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| Been made ill by your work? |
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| Been refused a Driver’s licence because of ill health? |
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Do you suffer from or previously have you ever had:
| Condition |
Yes/No |
Condition |
Yes/No |
| Diabetes |
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Shin Rashes/ Eczema |
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| High Blood Pressure |
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Anaemia |
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| Asthma |
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Headaches (frequent) |
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| Cough (frequent) |
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Heart Problems |
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| Rheumatic Fever |
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Chest Problems |
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| Arthritis |
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Fainting/ Dizziness |
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| Epilepsy/Fits |
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Hay Fever |
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| Shortness of Breath |
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Jaundice |
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| Legs/ Ankle Swelling |
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Period Problems |
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| Prostrate Problems |
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Varicose Veins |
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| Rupture |
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Ear Problems |
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| Eye Problems |
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Back Problems |
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Do you partake in any motor sports, climbing, diving, caving or private aviation?
Do you need glasses to read?
Have you worked in a dusty trade?
Have you ever had a head injury?
Do you take regular medication?
If yes, please confirm medication details in the box below:
Have you ever suffered from poor mental health?
If yes, please confirm details, including dates, in the box below:
Do you suffer from any other ailments?
If yes, please confirm details in the box below:
Is there any other ailment or pre-existing medical condition not included on this form of which your prospective employer should be aware?
If yes, please confirm details in the box below:
Confirm any additional information below:
To the best of my knowledge and belief, all the statements made in this form and any associated statements or questions are true and complete. I understand that if I am appointed and this information is inaccurate, I may be liable to dismissal.
