Centrum Care Homes Annual Health Declaration Form

Yearly Health Declaration Form

If the answer is yes to any of the questions in this section, please give full details in the space provided of the dates, duration and outcome of any health areas disclosed. The more information you can provide us will ensure that we can support you appropriately during your employment. When this document is completed a member of staff will meet with you to complete the Managers Assessment Form where you will be able to discuss the information provided. Centrum Care Homes has a duty of care to ensure that you are fit to work therefore a further medical report may be requested. If you are considered to have a disability, Centrum Care Homes also has a legal responsibility to make “reasonable adjustments” where practicable to ensure that you are treated fairly. Please note: you must inform your local office immediately if your health changes so that we can offer the correct support.
Name*

First NameLast Name
Workplace*
Do you have or have ever had:
Anything that affects your physical ability to walk, balance, bend etc…?*

YesNo
If yes, please provide additional information
Anything that affects your hearing (even after correction with a hearing device)?*

YesNo
If yes, please provide additional information
Anything that affects your eyesight in any way (even after lens correction)?*

YesNo
If yes, please provide additional information
Anything that causes severe pain?*

YesNo
If yes, please provide additional information
Anything that may affect your mental wellbeing (Anxiety, Depression, difficulties in dealing with Stress)?*

YesNo
If yes, please provide additional information
Any alcohol or drug dependency/misuse?*

YesNo
If yes, please provide additional information
Tuberculosis, Asthma, Bronchitis or any condition that may affect your breathing or chest?*

YesNo
If yes, please provide additional information
Anything that may affect your heart or blood pressure?*

YesNo
If yes, please provide additional information
Epilepsy or anything that may cause blackouts, seizures or fainting?*

YesNo
If yes, please provide additional information
Typhoid, Paratyphoid or Dysentery?*

YesNo
If yes, please provide additional information
Diabetes (Type 1 or Type 2)?*

YesNo
If yes, please provide additional information
Digestive or bowel disorder?*

YesNo
If yes, please provide additional information
Anything pertaining to your Thyroid?*

YesNo
If yes, please provide additional information
Anything relating to the Bladder or Kidney?*

YesNo
If yes, please provide additional information
Dermatitis or other skin problems?*

YesNo
If yes, please provide additional information
Varicose veins?*

YesNo
If yes, please provide additional information
Anything that has not been covered by the questions above?*

YesNo
If yes, please provide additional information
Other
Are you currently receiving medical treatment for a short term or long term health concerns?*

YesNo
If yes, please provide additional information
Have you any reason to believe you may be infected by any communicable disease?*

YesNo
If yes, please provide additional information
Do you have any allergies and if so are any of these life threatening?*

YesNo
If yes, please provide additional information
Have you ever left or been denied employment in an organisation on the grounds of ill health or been medically retired on the grounds of ill health?*

YesNo
If yes, please provide additional information
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?*

YesNo
If yes, please provide additional information
Is there anything else that affects your health that you wish to disclose to us?*

YesNo
If yes, please provide additional information
Vaccinations

Have you received vaccination for any of the following:
COVID*

YesNo
If yes, please provide date of vaccination (first dose)

DayMonthYear
Date
If yes, please provide date of vaccination (second dose)

DayMonthYear
Date
If yes, please provide date of most recent booster

DayMonthYear
Date
Tuberculosis BCG*

YesNo
If yes, please provide date of vaccination

DayMonthYear
Date
Rubella (German Measles)*

YesNo
If yes, please provide date of vaccination

DayMonthYear
Date
Tetanus*

YesNo
If yes, please provide date of vaccination

DayMonthYear
Date
Flu*

YesNo
If yes, please provide date of vaccination

DayMonthYear
Date
Hepatitis B (with certificate of vaccination)*

YesNo
If yes, please provide date of vaccination

DayMonthYear
Date
It may be a requirement of any assignment that you have a Hepatitis B vaccination. Restrictions may apply if you do not have a current certificate of vaccination.
Declaration
I certify that I am fit for work in the care industry and understand I must inform my office if anything changes with regards to my health and/or ability to work
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Yearly Health Declaration Form

Do you have or have ever had:

Other

Vaccinations

Declaration