FRONERI

Employment Medical Assessment
Name*
Date of joining*

MonthDayYear
Date
Position applied for*
Date of birth*

MonthDayYear
Date
Are you registered disabled ?*
Name and address of family doctor*
Telephone No.*
HEALTH QUESTIONNAIRE DECLARATION
I agree to report to the Doctor / Nurse / Manager

1. Before starting work if I suffer from any of the following:

Diarrhoea and / or vomiting

Skin Rashes

Boils, open cuts or spots

Discharge from ears, eyes, nose, gums or any other part of the body.

Cold, coughs, sinus infections, sore throat

2.After returning from sickness absence with any of the above conditions and BEFORE starting work.

3.After returning from a holiday abroad, if I suffered from diarrhoea and / or vomiting lasting more than 24 hours.

4.If any member of my household or close contact is unwell with diarrhoea and / or vomiting lasting more than 24 hours.

5.If I am found to be suffering from / or become a carrier of Typhoid, Paratyphoid or any Salmonella infections, Amoebic or Bacillary Dysentery, Cholera, or any Staphylococcal infection likely to cause food poisoning.

I understand that Food Hygiene Legislation requires me to report any of the above conditions and that it is a condition of my employment as a food handler to comply with the above requirements at all times.
Signed*

Clear
Date*

MonthDayYear
Date
Name (BLOCK CAPITALS)*
Health Assessment for all staff including Night Workers
Please answer all the following questions, answering Yes/No as appropriate. If answer is 'yes' to any question, please give details in 'Remarks' column.
Question - Do you or have you ever in your life, including childhood, suffered from any of the following:
Are you generally in good health?*

YesNo
Is your eyesight satisfactory (with or without glass) for all normal purposes?*

YesNo
Is your hearing satisfactory (without or without an aid) for all normal purposes?*

YesNo
Are you allergic to any foods?*

YesNo
Are you allergic to nuts?*

YesNo
Are you allergic to any medicines?*

YesNo
Do you have any heart problems, palpitations, shortness of breath?*

YesNo
Do you have high blood pressure?*

YesNo
Do you have circulation problems such as cold hands and feet?*

YesNo
Do you suffer from any chest or breathing problems?*

YesNo
Do you suffer from any stomach or bowel problems?*

YesNo
Do you suffer from Malaria?*

YesNo
Do you have any bouts of frequent diarrhoea or vomiting lasting 24 hours or longer?*

YesNo
Do you suffer from any of the following?*

DermatitisPsoriasisEczemaRashesSkin AllergiesFrequent boilsFrequent septic fingersAcneNone of the above
Have you any eye, ear, throat or nose problems?*

YesNo
Do you suffer from infections or discharges from the eyes, ears, nose or throat?*

YesNo
Do you have any special dietary requirements?*

YesNo
Have you visited your dentist within the last 6 months?*

YesNo
Do you have diabetes?*

YesNo
Do you suffer from bladder or kidney problems such as incontinence, or passing blood in urine?*

YesNo
Do you have any problems sleeping?*

YesNo
Any occurrences of blackouts, fits, epilepsy fainting attacks or dizzy or giddy spells?*

YesNo
Do you have migraines or frequent headaches?*

YesNo
Do you/have you suffered from nervous breakdown/nervous attacks, stress?*

YesNo
Have you suffered from back problems - causing time off work?*

YesNo
Have you any problems with joints or bones?*

YesNo
Do you have any difficulties affecting?*

StandingWalkingStair ClimbingLiftingUse of handsWorking at heights on ladders?Wearing closed or safety shoesNone of the above
Have you been abroad in the last 3 months?*

YesNo
If yes, please list the countries visited:
When did abroad did you:

Suffer any sickness, diarrhoea or bowel disorder?Suffer from any infectious conditions of the skin, nose, throat or eyes?have any flu-like symptoms?None of the above?
If you had flu-like symptoms do you still have these symptoms now?

YesNo
Have you been in contact with anyone who has typhoid, paratyphoid or cholera?*

YesNo
Do you use an inhaler?*

YesNo
Do you use a nasal spray?*

YesNo
Have you ever suffered from any accident or disease requiring hospital admission or an operation?*

YesNo
Have you stayed away from work (or school) in the last year with illness?*

YesNo
If yes, how long were you off for?
Have you had a chest X-ray in the past 5 years?*

YesNo
If yes, was it normal?
Have you had any special investigations e.g. cardiograph, ultrasound, barium X-rays, etc?*

YesNo
Any other illnesses?*

YesNo
Do you smoke?*

YesNo
If yes, how many do you smoke each day?
Do you drink alcohol?*

YesNo
If yes, say how much and what you normally drink in an average week?
Are you colourblind?*

YesNo
Identify the numbers imbedded in the pictures below:
Health Factors - Night Workers

(staff who may be expected to work between midnight and 5am)
Have you at any time suffered from the following:*

Diabetes, particularly where treatment with insulin injections on a strict timetable is required?Heart or circulatory disorders, particularly where physical stamina is affected?Stomach or intestinal disorders, such as ulcers or a conditions where the timing of meals is importantAny medial conditions affecting sleep?Any chronic chest disorders where night-time symptoms may be troublesome?Any medical condition requiring regular medication?None of the above
Are there, to your knowledge, any other relevant medical facts which may affect your fitness to work at night?*

YesNo
Declaration - All Applicants

I have answered all the questions to the best of my knowledge and belief, and agree to be examined by a doctor if so requested. I also agree to provide any samples and undertake any reasonable hygiene test required by the company. I understand that if I am found to have knowingly given wrong or false information my application and/or employment may be at risk.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Employment Medical Assessment

HEALTH QUESTIONNAIRE DECLARATION

Health Assessment for all staff including Night Workers

Health Factors - Night Workers