HEALTH DECLARATION

HEALTH DECLARATION
Name

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Please ensure you answer all questions on this form

Have you suffered from any of the following in the past 3 years:
Tuberculosis, asthma, bronchitis or any disease of the lungs? Yes/No
Heart disease or disorder, strokes or high blood pressure? Yes/No
Rheumatic Fever? Yes/No
Osteoarthritis, Rheumatoid Arthritis, or other painful inflammatory conditions? Yes/No
Back trouble i.e. slipped disc, lumbago or other mobility difficulties? Yes/No
Any neurological disorders e.g. Multiple Sclerosis or Epilepsy? Yes/No
Diabetes: Type 1 or 2 ? Please state 'No' if this does not include you.
Skin disease e.g. eczema or dermatitis? Yes/No, if Yes, please explain.
Any known allergies? Yes/No. If 'Yes', please provide further details
Recurrent stomach troubles, gastric disorders/vomiting? Yes/No
A hernia? Yes/No
Any hearing defects/difficulties in either ear? Yes/No. If 'Yes', please provide further details
Eye disease (including Colour blindness), visual difficulties? Yes/No. If 'Yes', please provide further details
Mental health complaints e.g. depression,Post-Traumatic Stress Disorder? Yes/No. If 'Yes', please provide further details
Had within the last 12 months or are awaiting any surgical operations or hospital appointments? Yes/No. If 'Yes', please provide further details
Received medical treatment during the past three months or awaiting treatment?Yes/No. If 'Yes', please provide further details
Received any immunisation or vaccines in the last twelve months? Yes/No. If 'Yes', please provide further details
Been diagnosed with any contagious illness or disease during the last twelve months:
Please tell us any other treatment or diagnosis information that you think is important for us to know. Comments:
Type a question
Disabilities

Do you have any disabilities that iCare might have to make adaptations for under the Disability Discrimination Act 1995?
If yes, please provide details below
I agree to a medical examination or report, or to respond to a request for further medical information, in the event that I am offered work by ¡Care, if deemed necessary.I authorise iCare to contact my own doctor or any other consultant or specialist to whom I have been referred. I acknowledge that any information gathered by iCare as a result may be used to determine what adjustments, if any, might need to be made so as to allow me to safely perform my duties. I certify that I have answered the questions truly and fully and that I am not aware of any other health reason which will, or may, affect my working capacity.I understand and agree to a Staff Risk Assessment being completed, in relation to my health, should this be appropriate to my working role.I understand that my Health Declaration will be kept in a confidential file which is only accessible by senior management.Onc I have started work for iCare I will inform them of any new health issues, should they arise and will complete a new Health Declaration.
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HEALTH DECLARATION

Disabilities