• Health Declaration Form

    Health Declaration Form

    April Complete Care Solutions

  • Form

  • We are committed to supporting all individuals and creating an inclusive environment. If you have any neurodiversity or conditions such as depression, stress-related or emotional issues, or any other condition that may affect your wellbeing at work (e.g., causing anxiety, panic attacks, or mood swings), please let us know if there are any adjustments or support that would help you. Sharing this information is entirely optional and confidential.*

  • 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?*
  • Back related problems, Rheumatism or Arthiritis*
  • Varicose Viens*
  • Any condition that affects your eyesight in our way ( after lens correction).*
  • Any condition that affects your hearing in any way (after correction with a hearing device).*
  • Any alcohol or drug dependency or misuse*
  • Do you suffer with Gastric disorders i.e. Digestive or bowel disorders*
  • Conditions that affecting sleeping or that cause excessive drowsiness*
  • Jaundice*
  • Typhoid, Paratyphoid, Dysentry*
  • Bladder or Kidney problems*
  • Dermatitus or skin conditions*
  • Epilepsy, diabetes, heart disease*
  • Any significant infectious diseases such as tuberculosis or hepatitis which may pose a risk if not treated.*
  • Mumps, Measels, Chicken Pox*
  • Any other current or recent medical condition or treatment which might affect your attendance or treatment at work*
  • Have you spent any time in hospital within the last 3 years
  • 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?*
  • Are you currently receiving any treatment or medication*
  • Are you currently receiving treatment for any ongoing health issues?*
  • Do you smoke*
  • Have you had any days off sick from work in the last year?*
  • Have you ever worked Nights?*
  • Have you suffered any health problems as a result?*
  • Rows

  • 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

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