Ocean fish & Riddlers Pre-Employment Health Questionnaire In Confidence
Surname
*
Other Names
*
Sex
*
Male
Female
Title
*
Mr
Mrs
Ms
Miss
Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Position applied for
*
Telephone No.
*
Post code
*
Work History
Previous Position Held
Position Start Date
.
Month
.
Day
Year
Date
Position End Date
-
Month
-
Day
Year
Date
Main Duties
Do you have another previous position that you would like to provide details for?
Yes
No
Previous Position Held (2)
Position Start Date (2)
-
Month
-
Day
Year
Date
Position End Date (2)
-
Month
-
Day
Year
Date
Main Duties (2)
Do you have another previous position that you would like to provide details for? (2)
Yes
No
Previous Position Held (3)
Position Start Date (3)
-
Month
-
Day
Year
Date
Position End Date (3)
-
Month
-
Day
Year
Date
Main Duties (3)
Do you have another previous position that you would like to provide details for? (3)
Yes
No
Previous Position Held (4)
Position Start Date (4)
-
Month
-
Day
Year
Date
Position End Date (4)
-
Month
-
Day
Year
Date
Main Duties (4)
Do you have another previous position that you would like to provide details for? (4)
Yes
No
Previous Position Held (5)
Position Start Date (5)
-
Month
-
Day
Year
Date
Position End Date (5)
-
Month
-
Day
Year
Date
Main Duties (5)
Name and Address of GP
*
Name and Address of next of Kin
*
Height
*
Weight
*
Alcohol Consumption Weekly
*
Are you a Smoker?
*
Yes
No
Daily amount:
Do you wear Glasses or Contact Lenses?
*
Yes
No
Date of Last Optician Visit
/
Month
/
Day
Year
Date
Do you suffer from colour defective vision?
*
Yes
No
Do you suffer from poor hearing in either or both ears?
*
Yes
No
Do you suffer from any condition preventing the wearing of protective footwear?
*
Yes
No
Do you suffer from any condition causing problems lifting or standing for long periods?
*
Yes
No
Are you currently taking any medicine or undergoing any treatment?
*
Yes
No
If yes, please give details:
Have you been absent from work due to illness during the last 12 months?
*
Yes
No
If yes, please give details:
Have you been referred to a specialist in the last 5 years or been admitted to hospital?
*
Yes
No
If yes, please give details:
Do you suffer from any other condition either mental or physical not raised above?
*
Yes
No
If yes, please give details:
Have you suffered from any of the following in the last 12 months?
*
Diarrhea
Vomiting
Gastro Enteritis
None of the above
If yes, please give details:
Have you suffered from any of the following in the last 12 months?
*
Typhoid
Para Typhoid
Dysentry Enteritis
None of the above
If yes, please give details:
Have you ever been stool tested positive following food poisoning?
*
Yes
No
If yes, please give details:
Have you been abroad during the last 6 months?
*
Yes
No
If yes, please give details:
Have you suffered recently from infections of the hands, fingers, ears, mouth or throat?
*
Yes
No
If yes, please give details:
Do you suffer from any skin complaint e.g. Eczema, Psoriasis, Acne?
*
Yes
No
If yes, please give details:
When was your last visit to the Dentist?
*
If not in the last year are you willing to go for a check up?
Yes
No
Have you or are you suffering from any of the following:
*
Frequent Coughs, colds, or Hay fever
Diabetes
Chest trouble e.g. bronchitis, asthma
Kidney or Bladder Trouble
High Blood Pressure
Stomach or Bowel problems
Back or Neck Trouble
Mental Health Issues
Broken or fractured limbs
Recurring headaches / migraines
Epilepsy / Blackouts / Fits
Hepatitis / Jaundice
Heart Trouble
Painful Joints
Piles or Varicose Veins
None of the above
Employee Name
*
Employee Signature
*
Date
*
/
Month
/
Day
Year
Date
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