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Employee Health Questionnaire

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  • Employee Health Questionnaire

    First NameLast NamePost Applied for

    Please state your number of days' sickness absence from work in the last 12 months

    Question

    Answer (please circle answer)


    Do you have any health/medical problems or physical limitations which might affect your ability to undertake this job (e.g. for jobs involving manual handling - bending down, pushing/pulling etc or any problems with backache or neck ache?

    YesNo


    Have you ever had any health/medical problems, tuberculosis or other chest problems?

    YesNo


    Are you having, or waiting for, medical treatment or investigations of any kind or on long term or regular prescribed medication, Have you ever had any alcohol or drug problems? (Excluding contraceptive pills)?

    YesNo

    Do you now, or have you ever suffered from:


    1. Eye disease or visual problems including impaired colour vision?

    YesNo


    2. Disabling headaches or migraine?

    YesNo


    3. Ear disease or hearing problems? Do you wear a hearing aid?

    YesNo


    4. Stomach or bowel problems (e.g. diarrhea or or indigestion)

    YesNo


    5. Jaundice or Hepatitis or other liver problems?

    YesNo


    6. Hernia (rupture)?

    YesNo


    7. Heart disease, high/low blood pressure or strokes?

    YesNo


    8. Epilepsy, fainting, dizziness or loss of consciousness?

    YesNo


    9. Any nervous system disorder (such as Multiple Sclerosis or Parkinson's disease)?

    YesNo


    10. Any serious head injury with or without skull fracture?

    YesNo


    11. Any skin problems (e.g. eczema, dermatitis) or recurrent infections?

    YesNo


    12. Allergies (to drug or any other substance) or hay fever?

    YesNo


    13. Any problems raising arms above shoulder height?

    YesNo


    14. Any problems with back ache or neck ache?

    YesNo


    15. Any time off work for backache or neck ache or aches/pains in other joints?

    YesNo


    16. Any problems with any other joints or muscles e.g. wrists, hands, ankles, feet or weak thighs?

    YesNo


    17. Any bone fracture, joint dislocation, or any surgery to muscles, joints or spine? Includes any artificial
    joints or metal plates.

    YesNo

    DECLARATION BY APPLICANT

    I certify that to the best of my knowledge and belief the above answers are true and complete. I understand that now and, if employed by the In Family Hands, in the future I have a duty to report any health condition or medication which could affect safety, concentration or performance at work.

     Please complete and return to the Recruiting Manager.

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