April Complete Care Solutions Health Declaration Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityCounty

Post code

Email*

example@example.com

Have you suffered from any of the following:

Please ensure all questions are answered or you will not be able to submit the form

Thank you April

Blackouts, Seizures or attacks of giddiness?*

YesNo

If you have answered Yes to the above question please provide full details

Back related problems, Rheumatism or Arthiritis*

YesNo

If you have answered Yes to the above question please provide full details

Depression, stress-related or emotional issues, any other conditions that may cause anxiety, panic attacks or mood swings*

YesNoOther

If you have answered Yes to the above question please provide give full details

Varicose Viens*

YesNo

Any condition that affects your eyesight in our way ( after lens correction).*

YesNo

If you have answered Yes to the question above please provide full details

Any condition that affects your hearing in any way (after correction with a hearing device).*

YesNo

If you have answered Yes to the question above please provide full details

Any alcohol or drug dependency or misuse*

YesNo

If you have answered Yes to the above question please provide full details

Do you suffer with Gastric disorders i.e. Digestive or bowel disorders*

YesNo

If you have answered Yes to the above question please provide full details

Conditions that affecting sleeping or that cause excessive drowsiness*

YesNo

If you have answered Yes to the above question please provide full details

Jaundice*

YesNo

Typhoid, Paratyphoid, Dysentry*

YesNo

Bladder or Kidney problems*

YesNo

If you have answered Yes to the question above please provide full details

Dermatitus or skin conditions*

YesNo

If you have answered Yes to the above question please provide full details

Epilepsy, diabetes, heart disease*

YesNo

If you have answered Yes to the above question please provide full details

Any significant infectious diseases such as tuberculosis or hepatitis which may pose a risk if not treated.*

YesNo

If you have answered Yes to the above question please provide full details

Mumps, Measels, Chicken Pox*

YesNo

Any other current or recent medical condition or treatment which might affect your attendance or treatment at work*

YesNo

If you have answered Yes to the above question please provide full details

Have you spent any time in hospital within the last 3 years

YesNo

If you answered yes please provide details

Any illness or medical condition that prevented you from attending work or your normal duties or activities for more than 1 week during the past 3 years?*

YesNo

If you answered yes to the above question please provide full details

Are you currently receiving any treatment or medication*

YesNo

If you have answered Yes to the above question please provide full details

Are you currently receiving treatment for any ongoing health issues?*

YesNo

If you replied Yes please provide details

Do you smoke*

YesNo

Have you had any days off sick from work in the last year?*

YesNo

Please provide details including how many days off

If you consume alcohol, what is your average alcohol intake per week in units?(1 unit = small glass of wine or ½ pint of beer) *

Have you ever worked Nights?*

YesNo

Have you suffered any health problems as a result?*

YesNo

If you have answered Yes to the above question please provide full details

Please indicate if you have had immunisations or vaccination for any of the following

	Yes	No
Tuberculosis
Hep B
Tetanus
Typhoid
Polio
Diphtheria Schick Test
Varicella
Rubella
Flu Vaccine
Covid 19 (Coronavirus)

Please provide your GP's name and surgery address including telephone number. We reserve the right to approach your GP to confirm the details of your application. if your health changes in anyway please inform April Complete Care Solutions immediately as failure to do so may invalidate your insurance.*

Please provide the name of your Next of Kin:*

Please provide the relationship to you *

Please provide contact telephone number *

I confirm that all the information I have given is true and accurate. Anything untrue or misleading will give the employer, April Complete Care Solutions, the right to terminate any offer of employment.

I hereby give April Complete Care Solutions permission to consult my GP for additional information pertaining to my medical history.

I also agree that April Complete Care Solutions may request a more thorough medical examination if applicable.

I consent to my data being collected, processed and stored from this form in
accordance with the relevant Data Protection and Protection laws.
copies of our policies and procedures are available upon request and are on our website.

This information is kept with my file and is protected under the Data Protection Act 2018

Date

Signature*