Health Questionnaire Form In Confidence Prospective employees are required to complete the following questions as fully as possible. Any false statements or omissions may prejudice the appointment or the continued employment of the applicant. All fields marked with are required. Full Name:   Date of Birth: Address:   Present Occupation: Proposed Occupation: Name and Address of Family Doctor:   Have you been declined Life Assurance on medical grounds? Yes No Are you a Registered Disabled Person? Yes No If so state disability: Have you had any long absences from work or periods in hospital ? Yes No If so, please give details and dates: Have you ever been examined as a contact of Tuberculosis: Yes No Details: Are you currently on any medicines or tablets ? Yes No Have you been taking prescribed medication for any length of time? Yes No If so, please give details: Give details of any family illness: What is your height: Weight: Have you been immunised against Hepatitis B? Yes No Have you been immunised against Tetanus ? Yes No   Have you ever suffered from any of the following ? Mental illness or nervous breakdowns, blackouts, headaches, fits or convulsions Yes No Chest trouble including asthma, tuberculosis, pleurisy or pneumonia Yes No High blood pressure, thrombosis, attacks of dizziness or any heart condition Yes No Rheumatic fever or arthritis Yes No Diabetes Yes No Chronic indigestion, ulcer or jaundice Yes No Any loss of weakness of limbs Yes No Urinary disease Yes No Skin trouble Yes No Hernia Yes No Defects of sight or hearing Yes No Back trouble Yes No Any other significant illness, disease or injury Yes No Any allergies to drugs, etc Yes No If so, please give details:   I agree to further information being obtained, if necessary, from my family doctor and I agree to a medical examination, if considered necessary. Email Address

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