Employee Health Declaration Form

Full Name :

Do you have or ever suffered with:

Rows	YES	NO	If YES, give details
Are you currently taking any medication tablets, special diets or injections?
Have you ever had to leave employment for health reasons?
Do you suffer blackout, fits of giddiness or have any condition of vision/hearing which may affect your ability to work?
Neurological, migraines, (including epileptic) symptoms, disorders or disease?
Is there any aspect current/ recent of your health /medical condition / treatment which may restrict or affect your ability or work performance?
Do you or have you suffered cardiovascular symptoms or pains, irregular blood pressure varicose veins, hematological disorders or diseases, asthma, bronchitis or tuberculosis?
Do you or have you ever suffered from stress, depression, mental illness or nervous breakdown, alcoholism or drug related symptoms?
Have you suffered from gastrointestinal, bowel, typhoid, paratyphoid or dysentery problems?
Have you any reason to believe you have been infected by a communicable disease?
Do you suffer from immune-deficiency symptoms e.g. (HIV positive) disease or disorder?
Bladder or kidney trouble?
Diabetes, thyroid or other gland problems?
Do you suffer from recurrent sore throat or have you ever been treated for MRSA infections?
Do you have any allergies?
Any accidents or illnesses or any other medical condition that prevented you from attending work, or carrying out normal duties or activities for more than 1 month during the past year?
Do you have any allergies?
Do you smoke?
Do you consume alcohol?
Are you allergic to any foods, drink, chemicals or anything else?
Have you been abroad in the past 2 yrs.? If YES fill details below

Have you got any history of medical screening? Please fill details below:

Date of most recent screen?

Date

ARE YOU CURRENTLY REGISTERED WITH A GP :

NAME OF GP

NAME OF PRACTICE

TELEPHONE NO :

NAME

EMAIL

SIGNATURE

DATE

Date

Employee Health Declaration Form

Medical Screening