Employee Medical Questionnaire

Surname

Forenames

Position

Address

Name and address of own doctor

Please answer all the following questions

Do you have any physical or mental impairment that could be classed as a disability under the Equality Act 2010?

Have you ever received compensation or a disability pension?

Have you ever had to give up any previous job for medical reasons?

Have you been off work continuously for more than a month during the last five years?

Have you ever had any operations requiring hospital admission for five or more days?

Is your eyesight normal (with glasses if worn)?

Is your hearing normal?

Do you regularly take tablets or medicine?

If yes, please give details below.

Have you ever had any of the following?

Diabetes

Tuberculosis

Angina

Any other heart trouble

Raised blood pressure

Peptic, gastric or duodenal ulcer

Indigestion for more than one week

Back trouble, lumbago, sciatica, "slipped disc"

Epilepsy, recurring blackout or fits

Have you ever had any of the following during the past five years?

Bronchitus, asthma, pneumonia

Dermatitis, eczema or any other skin trouble

Do you suffer from any of the following?

Migraine or severe recurring headaches

Anxiety, depression or any other nervous complaint

Fainting attacks or giddiness

Ear trouble, discharging or infected ear

Kidney trouble or urinary infection

If you have answered yes to any of the previous questions please give very brief details below

Have you ever had any other serious illness?

If yes, please give very brief details

Have you consulted a doctor about your health during the past 12 months?

If yes, please give very brief details below.

Busy Bee Recruitment treats personal data collected in this medical questionnaire in accordance with its data protection policy. Information about how data is used and the basis for processing the data is provided in our privacy notices for job applicants and employees.