Medical Questionnaire
(Must be completed before starting on site)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
The company ask the following questions with regards your health. This allows us to evaluate whether any additional risk assessment(s) need to take place with regards your work environment and / or equipment & machinery which you can or cannot operate.
How would you consider the state of your Health
Excellent
Good
Fair
Poor
Have you been absent from work in the last three years due to absence or Illness
Yes
No
Do you suffer for any reoccuring pain or injury
Yes
No
Are you currently taking any medication or using any therapy
Yes
No
Do you suffer from Epilepsy
Yes
No
Please list any known allergies that you have / suffer from
Are you an Insulin dependent Diabetic
Yes
No
Have you ever suffered from blackouts, dizziness or any condition which would cause sudden collapse or incapacity
Yes
No
Have you ever experiences discomfort or pain in the chest, shortness of breath question
Yes
No
If you answered YES to any of the above questions, please provide as much detail as possible including date(s) when the matters arose, what medical treatment was received and what was the medical advise issued at the time
DECLARATION. By ticking and submitting this form, I confirm that this is a true and accurate reflection of my overall condition of my health. I will also inform my supervisor / HR if any medical condition changes, to ensure that they have up to date information on any medical condition and determine if additional risk assessments are required.
I agree with this declaration
I do not agree with this declaration
Submit
Should be Empty: