MEDICAL QUESTIONNAIRE
Personal Information
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Work
*
UK
Europe
Doctors Name
*
Doctors Address
*
Questions
Do you have any physical or mental impairment that could be classed as a disability under the Equality Act 2010?
*
Yes
No
Have you ever had to give up any previous job for medical reasons?
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Yes
No
Have you been off work continuously for more than a month during the last 5 years?
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Yes
No
Will you have difficulty carrying out strenuous physical work including climbing ladders, working from scaffolding, bending, lifting and carrying?
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Yes
No
Are there any medical reasons why you should not do shift work?
*
Yes
No
Do you have any eyesight difficulties (glasses not included)?
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Yes
No
Do you have any hearing difficulties
*
Yes
No
Are you regularly taking any medication? If so, please provide details:
*
Yes
No
Details of Medication
Are you currently suffering from, or have you ever suffered from, any of the illnesses listed below?
*
Rows
Yes
No
Angina
Any other heart trouble
Lung disease
Stomach/bowel trouble
Jaundice/hepatitis
Joint problems/arthritis
Migraine or severe recurring headaches
Diabetes
Allergies
High blood pressure
Kidney/bladder problems
Any back/neck problems, eg, lumbago, sciatica, etc
Mobility problems
Epilepsy, recurring blackouts or fits
Fainting attacks or giddiness
Ear and/or eye problems
Depression/anxiety
Cancer
Any neurological disorder
Have you ever had any of the following during the past 5 years?
*
Rows
Yes
No
Asthma, Bronchitis, pneumonia
Dermatitis, eczema or any other skin problems
If you have answered “yes” to any of the above questions, please give further details and approximate dates where relevant. This is particularly important where you have a qualifying disability under the Equality Act 2010 as it will enable us to identify what, if any, reasonable adjustments can be made.
Are you currently under the care of a doctor, consultant or any other medical professional? If yes, please provide details.
Signature
*
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