Your Details (Confidential)
Full Name:
Address:
Date of Birth:
Nationality:
Home Phone Number:
Mobile Phone Number:
Email:
Can we contact you via email?
National Insurance Number:
Next of Kin
In case of emergency whom would you like us to contact?
Contact 1
Name:
Tel No.:
Mobile Phone Number:
Relationship to you:
Address:
Contact 2
Name:
Tel No.:
Mobile Phone Number:
Relationship to you:
Address:
Data Protection: The information you provide on this form will be used by the Company for the purpose of assessing your fitness for work and will be handled in line with the Company’s Data Protection Policy.
In order for us to fulfil our contractual and/or legal obligations to you, it may be necessary to share some of this information with medical or healthcare professionals, should advice be needed to validate your fitness to undertake your role, or in support of any reasonable adjustments that may be required. In the event that this is necessary, we will seek your consent.
This document will be kept on your personnel file (hard copy and/or electronic) for the duration of your employment. We will retain your personnel file for a period of 7 years after your employment has ended (or in line with current legislation at that time). Please refer to the Company’s Data Protection Policy for more information relating to how the Company processes your personal data and your rights.
Health Questionnaire
Full Name:
Address:
Name and address of your own General Practitioner:
Data Protection: The information you provide on this form will be used by the Company for the purpose of assessing your fitness for work and will be handled in line with the Company’s Data Protection Policy.
In order for us to fulfil our contractual and/or legal obligations to you, it may be necessary to share some of this information with medical or healthcare professionals, should advice be needed to validate your fitness to undertake your role, or in support of any reasonable adjustments that may be required. In the event that this is necessary, we will seek your consent.
This document will be kept on your personnel file (hard copy and/or electronic) for the duration of your employment. We will retain your personnel file for a period of 7 years after your employment has ended (or in line with current legislation at that time). Please refer to the Company’s Data Protection Policy for more information relating to how the Company processes your personal data and your rights.
Please answer all the following questions by indicating either Yes or No. If you answer Yes to any question please give more information in the Remarks column.
1. Disturbed sleeping patterns requiring medical attention?
Please elaborate if the answer is YES:
2. Have you worked / do you work a permanent/rotating night shift pattern?
Please elaborate if the answer is YES:
3. Any medical condition requiring medication to a strict timetable?
Please elaborate if the answer is YES:
4. Has your work ever had a direct adverse effect on your health? (E.G vibration white finger, noise induced hearing loss or work related stress):
Please elaborate if the answer is YES:
5. Problems with the ears, eyes? Any defect of hearing or sight?
Please elaborate if the answer is YES:
6. Have you consulted or been referred to a medical or surgical specialist in the last 2 years?
Please elaborate if the answer is YES:
7. Have you had any serious injuries? Fracture, head injury, etc.?
Please elaborate if the answer is YES:
8. Any nose, throat or chest illnesses? E.g. Hay fever, tonsillitis?
Please elaborate if the answer is YES:
9. Any stomach, bowel or intestinal trouble, e.g. ulcer, attacks of diarrhoea, chronic indigestion? (YES or NO)
Please elaborate if the answer is YES:
10. Have you had a nervous breakdown or suffer with any other mental illness?
Please elaborate if the answer is YES:
11. Have you suffered from migraine, fits, attacks of unconsciousness or dizziness?
Please elaborate if the answer is YES:
12. Do you have sensitivity to chemicals? (e.g. detergent)
Please elaborate if the answer is YES:
13. Do you have any skin trouble? E.g. Eczema, Dermatitis?
Please elaborate if the answer is YES:
14. Have you suffered from heart trouble, high blood pressure, circulatory problems or diabetes? (YES or NO)
Please elaborate if the answer is YES:
15. Do you suffer from lumbago, sciatica, or other prolonged back pain?
Please elaborate if the answer is YES:
16. Have you had a rupture (Hernia)?
Please elaborate if the answer is YES:
17. Do you suffer from any known allergies?
Please elaborate if the answer is YES:
18. Do you have any breathing difficulties? (e.g. Asthma)
Please elaborate if the answer is YES:
19. Are you having, or waiting for any medical treatment or investigations at present?
Please elaborate if the answer is YES:
20. Do you have any serious illness not included in the above questions?
Please elaborate if the answer is YES:
21. Are there any other health factors that might affect your fitness for work?
Please elaborate if the answer is YES:
22. Do you have or have you ever had any significant health problem, impairment/disability (physical or mental) or learning difficulties that may affect your ability to undertake the tasks set out in the job description of the post offered?
Please elaborate if the answer is YES:
23. Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?
Please elaborate if the answer is YES:
Declaration
I declare that the information given on this document, is to the best of my knowledge, a true and complete account of my medical history and that failure to disclose details of my medical history may prejudice continued employment with the Company.
