Fitness To Work

TES207v1.1

Your E-mail*

Department*

Date*

DayMonthYear

Date of Birth*

DayMonthYear

Gender

	Male	Female
Gender

Do you suffer from (where "yes" please provide additional info below):

	Yes	No
Diabetes
Asthma or Bronchitis
Back, neck, shoulder, arms, hands or wrist problems
Fits, faints, blackouts or dizzy spells
Heart or circulatory disorders
Other lung conditions
Arthritis, muscle or joint problems
High Blood pressure
Stomach or intestinal disorders
Any condition which causes difficulties sleeping
Chronic chest disorders, especially if night-time symptoms are troublesome
Any medical condition requiring medication to a strict timetable
Do you have any madical implants, pacemakers, or similar devices that could be affected by RF sources
Any other health factors

Additional Comments & Other Medical Conditions. You must inform the company such that any statutory duty of care can be properly exercised, even if any conditions are only short term.

You must inform the company of any health or medical issues that may impair your ability to do your job, such that any statutory duty of care can be properly exercised, even if any conditions are only short term.

Please advice the company in writing of any other medical condition as it occurs that may affect your work duties. If any condition is long term then a medical assessment may be required from either your own Doctor or from a company resourced medical expert.

DECLARATION

I, the undersigned, confirm that the above is correct to the best of my knowledge.

I, the undersigned, confirm that any medical condirion that I am aware of does not impair my ability to do my job.

Your Signature*