PRE-EMPLOYMENT IVIEDICAL STATEIVIENT OF HEALTH

FirstName: a+ e`C' K`UwlftR` surname: c4tiu

Full Home Address: K`HI -Q>ftNTqL Tel. .-

Applied FO ate Completed:

Date of Birth: I.".ALE
5% I STD 1 qo' D I FEMALE LJ Cn tl T I N Ci i E Ltl N I C f f)iN

SOCIAL llISTORY

Smoking Alcohol H®ight: Fi+ 4 IncJh

No of cigarettes/cigars per day:
Did you ever smoke?
p tJL u rNoO:f:u.n::,?:;c:h:i.=i?m*i weioht: 6D ng
Wrien did you stop? glass Of wine)

I YEe b any q`I..eon b..o`r. B1- irmm t`~ I-I.ciiTI-ri-, h th. box on di. rth
1. Do you have any illness/Lmpairment/disability (physical or HyEs oro
psychological) which may affect your `^/ork?
2. Have you ever had any illness/impairment/disability which HYES JNO
may riave been caused or made worse by your cork?

3. Are you having, or waiting for treatment (including EYES UNO

medica(ion) or investigations at present?

4. Do you think you may need anyadjustmen. orassi.tanc® to DVEs vilNo

help you to do the job?

5, How many days have you had sick in the lasttwo years? 2±ng€ -
the last two years, please give
6. ITyou liave had any peliods Of absence from `rolk due to sickness for more than t`Aro `^/eeks in
details:

7. Have you ever been considered lndical unfit for any EyEs ufo
previous employment?
8. Hasanyabnormalityeverbeen detectedasa resultofachest DYES JNO
xrty?
9. Are you atpresentsufferingfrom orhave suffered in the last EyEs urfuo
five years from any Of the following?

Defective vision HyEs urfuo

Persistent cough EYES ulNO

Bronchitis/emphysema DyEs rfNO

Recu rring sto rna ch/bo`rel trouble EyEs rfNO

Tuberculosis HYES JNo

Recurring bladder trouble
DYES ufo

Asthma HyEs u2rf`O

Pneumonia/pleurisy
dvEs j24
Fitsn]lackoutsrfainting attacksfepik!psy
gyES givo

Back strain or trouble/pain

EYES JNO

Breathlessness
HyEs j2rNO

Hernia rupture
HyES Of

Ear trouble/deafness
.yES J,No
Chest disease/pe in DYES givo

Epilepsy HyEs j7rNO

Stroke EyEs €rdo

Varicose vein. EYES JNO
Severe liay fever or any other alk}rgy ovEs ufo
Diabetes nyEs jzrNO

High blood pressure DyEs Onto

Kidney disease DYES JNO

Drug/alcohol prchlemstdopendence DyEs JzrNO

Arthmis/knee or liip rophcement

Muscle or joint trouble EyEs uzrNO

Serlous inju ry/accidem HyEs JzrNO

Recurring headaches or migraines

DyEs dNo
Typhoid / Dysentery DYES JNO
Bowel trou EYES J`No
Heart d isease DYES J/No
Colour blindness DYES JNO

Thrombosi3 / Ieo or foot problem DyEs uarNO

Fear Of enclosed / open spaces DYES JZINo

or any other
EyEs jrfuo
Skin condition?

Serious illness/operation EyEs lrNO

injury / Concussion / Giddineco HyEs JfNo

Psychiatric illnesses , trouble with nerves, depression,

anxiety or stress related illness

Any other significant infection

?
 If YES to any quesGon below, olease I)rovide further jnfomation ill the box on the riaht.

10.Are you registered disabled or do you have any disability

which you consider `rould impact on the job for which you nyEs vFfro
are applying?

11. Please indicate if you have any disabilities which atfect: HYES JNO

Standing DYES givNO

Manual handling DyEs u2rfuo

Walkino DYES utNO

Use of your hands EYES j2fuo

Bending/sketching HyEs urfo

Climbing stairs ,,I,||JEYES ufoNATIONS

NATIONHaveyoueverbeenvaccinatedforanyOfthefollowing:(«/aadwisobfofor./oq to ®rrsuro thafyo(/r vaccmatoes are up to drfe./

Tub.reulosis YES D NO Date:

BCG/Matoux/HeadITME j7fis ENo Date:

Rubella (German Measles) Test YES I NO Date:

Rubella (Geman Measles) Vaccine urfEs UNO Irate:

Tetanus YES H NO Date:

Polio SDNO Date:

Hepatitis a J7<ES DNo Date:

I,'I=,II,i,I[,Ill •].I-I.I:LM-.]llL=l:I,T/T±|]L.]LII|I,TLT7]IIrtT.I.-.nL`I.T-w.ili,i[aLiT.-im|mi©2|

GP NAME:
I)/2 . L4Xrll KA^/7? i flyu^-_,+'^'^^J(/,(J,in
List any medication that you are taking: AI U

SIGNATURE

STAMP:
P_i u_i i
1]\. \utEt mn^ £`iHu,_.,``
I I, I,±, =,i, I I.I L|

I hereby declare that all the above answers are, to the best of my beliehelpindeterminingmymedicalffroessforthepostforwhichIambeingf, true and complete and I have not withh61aconsidered.IalsoherebydeclaretliatIwilli!nylh-fo rrritton , whieh wouldinfomtheHRDepartmentof

any injury or ailment subsequently sustalned to me since completing this form.

I understand that failure to disclose anv material info rmation could lead to m\/ aDE)oinhent beina terminated.

§ionedBycandid.te: n£VA hut €wl, I Date: |G/6)i/2jg2_I