Confidential
Name:
Date of Birth:
Home Address:
Name & Address of your 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.
| Have you ever suffered from, or had any symptoms of the following: |
Yes/No |
Please elaborate if the answer is YES: |
| 1. Disturbed sleeping patterns requiring medical attention? |
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| 2. Have you worked / do you work a permanent/rotating night shift pattern? |
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| 3. Any medical condition requiring medication to a strict timetable? |
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| 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.) |
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| 5. Problems with the ears, eyes? Any defect of hearing or sight? |
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| 6. Have you consulted or been referred to a medical or surgical specialist in the last 2 years? |
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| 7. Have you had any serious injuries? Fracture, head injury, etc.? |
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| 8. Any nose, throat or chest illnesses? E.g. Hay fever, tonsillitis? |
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| 9. Any stomach, bowel or intestinal trouble, e.g. ulcer, attacks of diarrhoea, chronic indigestion? |
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| 10. Have you had a nervous breakdown or suffer with any other mental illness? |
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| 11. Have you suffered from migraine, fits, attacks of unconsciousness or dizziness? |
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| 12. Do you have sensitivity to chemicals? e.g. detergent |
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| 13. Do you have any skin trouble? E.g. Eczema, Dermatitis? |
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| 14. Have you suffered from heart trouble, high blood pressure, circulatory problems or diabetes? |
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| 15. Do you suffer from lumbago, sciatica, or other prolonged back pain? |
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| 16. Have you had a rupture (Hernia)? |
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| 17. Do you suffer from any known allergies? |
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| 18. Do you have any breathing difficulties? e.g. Asthma |
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| 19. Are you having, or waiting for any medical treatment or investigations at present? |
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| 20. Do you have any serious illness not included in the above questions? |
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| 21. Are there any other health factors that might affect your fitness for work? |
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| 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? |
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| 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? |
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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.
