Health Questionnaire

Health History Questionnaire

All questions contained in this questionnaire are strictly confidential and will become part of your employment record.
Name

First NameLast Name
Gender
Birth Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Marital Status
GP Details
GP Name/ Surgery
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tel No
Personal Health History
Height
Weight

Childhood Diseases and Immunisation

Rows	Dates Immunisation Received
Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio
Tetanus
Hepatitis
Influenza
Pneumonia

Additional Information

Rows	Yes	No
Have you been tested for MRSA (methicillin Resistant Staph Aureus)?
Have you had skin complaints? EG. Dermatitis, Eczema, Psoriasis
Do you have vision or hearing loss?
Have you had any heart problems?
Have you had any bowel infections?
Do you have any Allergies
Do you have Diabetes?
Have you had any Liver Problems?
Have you had and Lung problems
Have you ever suffered from Black outs?
Have you ever had any mental health problems?
Have you ever had back/mobility problems?
Have you ever had any joint problems?
Have you ever had any other infections?
If you answer yes to any of the questions below, please give details in box provided.
Have you ever been refused a job on health grounds?
Have you been off work due to illness for more than 2 weeks?

How many days off sick have you had within last two years?
Please use the section below to give further details of any questions answered on previous section.
I understand that giving false information with regards to my medical history and fitness may lead to termination of my contract and services.

To the best of my knowledge the above information is correct.
Print Name
Print Name
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

Health History Questionnaire