Language
English (UK)
Polski
PRE-EMPLOYMENT HEALTH QUESTIONNAIRE
Name
*
Title
First Name
Middle Name
Last Name
Birth Date
*
Please select a day
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Day
Please select a month
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Month
Please select a year
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Year
Email
*
example@example.com
Colour of Eyes:
Colour of Hair:
Height:
Weight:
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Next
Food Hygiene History
Have you ever had:
Yes
No
Typhoid
Paratyphoid
Ear trouble
A running ear
Chest trouble - cough or phlegm
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General Health History
Do you have or have you ever suffered from:
Yes
No
Fainting attacks
Fits or blackouts
Dizziness
Mental Illness
Recurring headaches
Ear trouble or deafness
Eye trouble or defective vision corrected by glasses/lenses
Recurring chest disease
Asthma
Heart trouble
High blood pressure
Varicose vein trouble
Back/Neck trouble
Other muscle or Joint trouble
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General Health
At Present are you suffering from:
Yes
No
A cough with phlegm
Acne, boils, styles or septic fingers
A running ear
Diarrhoea, stomach pain or fever
Skin trouble
Diabetes
Recurring stomach trouble
Recurring bowel trouble
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Disabilities
NOTE: It is the policy of the Pamela Neave Employment Group not to discriminate directly or indirectly against people on ground of Sex, Marital Status, Race, Colour, Ethnic Origin, Disability or Age, nor do we discriminate in our advertising and selection, offering training or providing health benefits and services and every vacancy will be open equally to all those who meet the requirements of the job specification.
Have you any disabilities affecting:
Yes
No
Standing
Walking
Stair Climbing
Lifting
Use of the hands
Work at heights
Driving
Do you have any disabilities and special needs?
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General Enquiry
In the past two years have you been off work because of illness or injury?
Yes
No
If yes, please state reasons and indicate how many working days were lost?
Are you at present having any treatment or medicine prescribed by a doctor? (Excluding contraceptive pill)
Yes
No
If yes, please detail
Have you left any job on health grounds?
Yes
No
Have you had any operations, serious accidents or any illness not previously mentioned?
Yes
No
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Next of Kin / Emergency Contact
Please provide details of who to contact in-case of an emergency?
Name
Mr.
Mrs.
Miss.
Ms.
Dr.
Title
First Name
Last Name
Email
example@example.com
Phone number
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Doctor Information
Please provide Name and address of your doctors surgery
Phone number
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I declare that to the best of my knowledge the answers to the questions on this form are correct and I am not suffering from any disease or illness, the presence of which I have not revealed. I understand that a false declaration may lead to subsequent termination of my employment.
Date
-
Day
-
Month
Year
Date
Hour Minutes
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