Health Questionnaire

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. This form will remain private and confidential.

Do you have Tuberculosis, Asthma, Bronchitis, Chest Problems? *

Yes

No

If, yes please provide details.

Do you have Chest Pain, Heart Condition, Or Raised Blood Pressure? *

Yes

No

If, yes please provide details.

Do you have Blackouts, Fits, Or Attacks Of Giddiness? *

Yes

No

If, yes please provide details.

Do you suffer from Depression, Mental illness or nervous breakdowns? *

Yes

No

If, yes please provide details.

Do you have Rheumatism or arthritis? *

Yes

No

If, yes please provide details.

Do you have Back trouble? *

Yes

No

If, yes please provide details.

Do you have Typhoid, Paratyphoid or any other infectious disease? *

Yes

No

If, yes please provide details.

Do you have Digestive or Bowl Disease? *

Yes

No

If, yes please provide details.

Do you have Diabetes, thyroid or other gland trouble? *

Yes

No

If, yes please provide details.

Do you have Bladder or Kidney Trouble? *

Yes

No

If, yes please provide details.

Do you have Dermatitis or Skin Trouble? *

Yes

No

If, yes please provide details.

Do you have Varicose veins? *

Yes

No

If, yes please provide details.

Do you have Vision or Hearing Problems? *

Yes

No

If, yes please provide details.

Do you have any other accidental, operation or illness? *

Yes

No

If, yes please provide details.

Have you any reason to believe you may be infected with any other communicable disease? *

Yes

No

If, yes please provide details.

Do you have any Other Current or Recent Medical conditions or treatment which might affect your attendance and performance at work? *

Yes

No

If, yes please provide details.

Do you have 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? *

Yes

No

If, yes please provide details.

Do you have 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 adjustments required in relation to work *

Yes

No

If, yes please provide details.

Do you have any condition where the timing of a meal is particularly important? *

Yes

No

If, yes please provide details.

Do you have any medical condition which affects your sleep? *

Yes

No

If, yes please provide details.

Do you suffer from chronic chest disorder (such as asthma) where night time symptoms are particularly troublesome? *

Yes

No

If, yes please provide details.

Do you suffer from any medical condition requiring medication at strict times e.g epilepsy or thyroid disease? *

Yes

No

If, yes please provide details.

Have you had depression, stress, nervous disorders, or other mental ilness, alcohol or drug addiction in the last two years? *

Yes

No

If, yes please provide details.

Are you aware of any other health factors that may affect your fitness to carry out your work at your contracted hours? *

Yes

No

If, yes please provide details.

Do you smoke? *

Yes

No

If, yes how many cigarettes a day?

Do you drink? *

Yes

No

If, yes how many units a week?

I can confirm that I have answered all the questions above honestly and truthfully.

Full Name

Date

Signature