Pre-Employment Health Questionnaire Form

* Indicated fields must be completed

Private and Confidental

Position Applied For*

Title*

First Name*

Last Name*

Date of Birth*

Place of Birth*

Age*

Nationality*

National Insurance (NI) No*

Phone*

General Practitioner Details

General Practitioner*

Street Address*

City*

State / Province / Region*

Post Code*

Country*

All candidates are required to complete the following questionnaire. All information will be treated privately and confidentially. All candidates are asked to answer each question by placing a tick in the relevant box. Should you answer Yes for any question, please give full details in the space provided on the next section.

Have you suffered or are you suffering from any of the following?

Any skin disease (including dermatitis and eczema)?*

Discharge or disinfection of the ear or hearing defect?*

Asthma or hay fever or sufficient severity to require time off work?*

Any allergies (including sensitivity to antibiotics or other drugs)?*

Discharge from the nose, recurrent sore throat or sinusitis?*

Bronchitis or pneumonia?*

Tuberculosis?*

Recurrent diarrhoea, vomiting or dysentery?*

Typhoid, paratyphoid, hepatitis, entities, enteric fever?*

Recurrent boils or septic infections?*

Have you visited the dentist in the last 12 months?*

Have you ever suffered from high blood pressure?*

Have you ever been diagnosed as suffering from any type heart disease?*

Do you suffer from persistent headaches or migraine?*

Depression, nervous breakdown or mental illness, psychiatric treatment?*

Arthritis, rheumatism, back problems or sciatica?*

Are you aware of any reason why you cannot lift objects?*

Rupture, varicose veins or foot ailments?*

Indigestion or stomach pains?*

Kidney infection?*

Bladder infection?*

Eye disease, injury or significant defects of vision not corrected by spectacles?*

Date of last eye test*

Diabetes?*

Have you ever been admitted into hospital?*

Have you ever had to stop work for more than one month for medical reasons?*

Do you have any special needs or disability?*

Are you currently under medication prescribed by your GP?*

If you have answered YES to any of the questions, please provide details below: – Stating with the relevant question number

Declaration

I understand and acknowledge that should I knowingly make a false statement regarding my medical history either in answering the above questions or to any medical examiner, or should I wilfully conceal any material fact, I will if engaged be liable to have my contract terminated. In the event of any health queries I consent to my general practitioner supplying relevant information to the company medical advisor. I confirm that there is nothing in my current circumstance that would be detrimental to me working either on a shift roaster basis throughout the night.

Sign*

Print Full name

Date*

Person Centred Care

Specialist Support

Live-in Care

Supported Living

Respite Care

Domiciliary Care

PRE-EMPLOYMENT HEALTH QUESTIONNAIRE FORM