• Health Questionnaire

  • Date Of Birth
     - -

  • 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.

  • Tuberculosis, asthma, bronchitis or chest problems?*
  • Chest pain, heart condition or raised blood pressure?*
  • Blackouts, fits or attacks of giddiness?*
  • Depression, mental illness or nervous breakdown?*
  • Rheumatism or arthritis?*
  • Back trouble?*
  • Typhoid, paratyphoid or other infectious disease?*
  • Digestive or bowel disease?*
  • Diabetes, thyroid or other gland trouble?*
  • Bladder or kidney trouble?*
  • Dermatitis or skin trouble?*
  • Varicose veins?*
  • Vision or Hearing problems?*
  • Any other accident, operation or illness?*
  • Have you any reason to believe you may be infected with any communicable disease (example COVID 19)*
  • Any other current or recent medical condition or treatment which might affect your attendance or performance at work?*
  • Do you intend to work night duties on a regular basis?*
  • 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?*
  • 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 special adjustments required in relation to work.*
  • Do you smoke?*
  • Should be Empty: