Health Questionnaire Form (2) Pre-Employment Medical QuestionnairePlease 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:Car Transporter DriverDepartmentAutomotivePersonal InformationName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Email* Address* Street Address City County / State / Region ZIP / Postal Code Mobile*TelephoneDate of birth* Day Month Year National Insurance Number*Would you object to being contacted on your work number (if necessary) Yes No Name and address of your own General Practitioner* Street Address Address Line 2 City County / State / Region ZIP / Postal Code TelephoneMedical HistoryHave you previously...Had an operation?* Yes No Please elaborate if the answer is YESBeen seriously injured?* Yes No Please elaborate if the answer is YESReceived in-patient treatment for a physical or mental condition?* Yes No Please elaborate if the answer is YESBeen refused or dismissed from employment for health reasons?* Yes No Please elaborate if the answer is YESBeen made ill by your work?* Yes No Please elaborate if the answer is YESBeen refused a Driver’s licence because of ill health?* Yes No Please elaborate if the answer is YESMedicalDo you suffer from or previously have you ever had:Diabetes* Yes No Shin Rashes/ Eczema* Yes No High Blood Pressure* Yes No Anaemia* Yes No Asthma* Yes No Headaches (frequent)* Yes No Cough (frequent)* Yes No Heart Problems* Yes No Rheumatic Fever* Yes No Chest Problems* Yes No Arthritis* Yes No Fainting/ Dizziness* Yes No Epilepsy/Fits* Yes No Hay Fever* Yes No Shortness of Breath* Yes No Jaundice* Yes No Legs/ Ankle Swelling* Yes No Period Problems* Yes No Prostrate Problems* Yes No Varicose Veins* Yes No Rupture* Yes No Ear Problems* Yes No Eye Problems* Yes No Back Problems* Yes No Do you partake in any motor sports, climbing, diving, caving or private aviation?* Yes No Do you need glasses to read?* Yes No Have you worked in a dusty trade?* Yes No Have you ever had a head injury?* Yes No Do you take regular medication?* Yes No If yes, please confirm medication details in the box below:Have you ever suffered from poor mental health?* Yes No If yes, please confirm details, including dates, in the box below:Do you suffer from any other ailments?* Yes No 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?* Yes No 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. TO CONTINUE PLEASE CLICK SUBMIT AND READ THROUGH THE DOCUMENT THEN SIGN AT THE BOTTOM. CLICK AGREE AND SIGN THIS WILL SEND THE DOCUMENT BACK TO IGLOO
