Health Questionnaire

Health Questionnaire
Regulation 21 of the Health and Social care Act 2008 (Regulated Activities) (Amendment) Regulations 2015 states that a person employed for the purposes of carrying on a regulated activity must be physically and mentally fit for that work.

Please answer the following questions:
1. How many days were you absent from work due to sickness in the last year?
2. Have you ever suffered from: Allergies, eczema, dermatitis or other skin troubles?

YesNo
3. Do you suffer from: Epilepsy, migraine, asthma, angina, heart trouble or any condition requiring long-term medical help or a strict medication timetable?

YesNo
4. Have you ever suffered from: Mental illness including anxiety, depression or nervous debility?

YesNo
5. Have you ever required treatment for: Hernia or rupture, rheumatism, back problems, slipped disc, sciatica or Repetitive Strain Injury (RSI)?

YesNo
6. Do you suffer from: Diabetes, ulcers, stomach or other intestinal disorders?

YesNo
If you have answered yes to any of the questions above, please provide further details below
Declaration:
I hereby confirm that I know of no reason, in relation to either my physical or mental health, why

I would be unable to undertake the duties required for the post applied for.

I hereby confirm that I have provided truthful and accurate responses to all the questions above to the best of my knowledge. I understand that any failure to disclose relevant information may impact my employment with the company.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Health Questionnaire

Declaration: