Pre-Employment Health Questionnaire Form

Pre-Employment Health Questionnaire Form

Step 1 of 3

PRIVATE AND CONFIDENTIAL
* indicated fields must be completed
Position Applied For:

Title*
First Name:*

Middle Name:*

Last Name:*

Forenames (If applicable):

Date of Birth:*
DD slash MM slash YYYY

Place of Birth:*
Country

Age:*
Please enter a number from 18 to 65.
Nationality:*

National Insurance (NI) No:*

Telephone Or Mobile Number:*
(Including STD Code)
Disclosure and Barring Service (DBS) Details:
Passport Number or Biometric residence permit: UK:*

Drivers Licence Number:

Address Details:*
Street Address: City: County: Postal Code: Country

General Practitioner Details:
General Practitioner:*

Address:*
Street Address City County / State / Region ZIP / Postal Code Country

All candidates are required to complete the following questionnaire. All information will be treated privately and confidentially. All candidates are asked to answer each question by placing a tick in the relevant box. Should you answer Yes for any question, please give full details in the space provided on the next page.
Have you had your Covid vaccine*

YES

NO
COVID Vaccine*
Select All
First Jab
Second Jab
COVID Booster
Have you suffered or are you suffering from any of the following:
Any skin disease (including dermatitis and eczema)?*

YES

NO
Discharge or disinfection of the ear or hearing defect?*

YES

NO
Asthma or hay fever or sufficient severity to require time off work?*

YES

NO
Any allergies (including sensitivity to antibiotics or other drugs)?*

YES

NO
Discharge from the nose, recurrent sore throat or sinusitis?*

YES

NO
Bronchitis or pneumonia?*

YES

NO
Tuberculosis?*

YES

NO
Recurrent diarrhoea, vomiting or dysentery?*

YES

NO
Typhoid, paratyphoid, hepatitis, entities, enteric fever?*

YES

NO
Recurrent boils or septic infections?*

YES

NO
Have you visited the dentist in the last 12 months?*

YES

NO
Have you ever suffered from high blood pressure?*

YES

NO
Have you ever been diagnosed as suffering from any type heart disease?*

YES

NO
Do you suffer from persistent headaches or migraine?*

YES

NO
Depression, nervous breakdown or mental illness, psychiatric treatment?*

YES

NO
Arthritis, rheumatism, back problems or sciatica?*

YES

NO
Are you aware of any reason why you cannot lift objects?*

YES

NO
Rupture, varicose veins or foot ailments?*

YES

NO
Indigestion or stomach pains?*

YES

NO
Kidney infection?*

YES

NO
Bladder infection?*

YES

NO
Eye disease, injury or significant defects of vision not corrected by spectacles?*

YES

NO
Date of last eye test*
MM slash DD slash YYYY

Diabetes?*

YES

NO
Have you ever been admitted into hospital?*

YES

NO
Have you ever had to stop work for more than one month for medical reasons?*

YES

NO
Do you have any special needs or disability?*

YES

NO
Are you currently under medication prescribed by your GP?*

YES

NO

If you have answered YES to any of the questions, please provide details below: – Stating with the relevant question number
Declaration:
I understand and acknowledge that should I knowingly make a false statement regarding my medical history either in answering the above questions or to any medical examiner, or should I wilfully conceal any material fact, I will if engaged be liable to have my contract terminated. In the event of any health queries I consent to my general practitioner supplying relevant information to the company medical advisor. I confirm that there is nothing in my current circumstance that would be detrimental to me working either on a shift roaster basis throughout the night.
Applicant’s Name*

Applicant’s Date of Completion:*
MM slash DD slash YYYY

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Call Us : +44 7539 298995
Address: 196 Queensway Bletchley, Milton Keynes. MK2 2ST.
Email: info@ccareservices.co.uk

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