Pre-Placement Health Assessment Form

Confidential to Healthwork

General Guidance

Please complete in BLOCK CAPITALS using BLACK/BLUE ink only. Please complete your name and date of
birth on the bottom of every page. You should complete this form as fully and accurately as possible. It is not
acceptable to leave any questions blank: any omissions will result in your recruitment being delayed. If a
question does not apply to you, please write ‘nil’ or ‘not applicable’. In any questions where further details
are required, please give as much information as possible, i.e. date health problem occurred, severity of
problem, details of treatment, and any ongoing problem or restrictions of lifestyle that you have currently. If
you are fully recovered, please state this also. It may be necessary to contact your GP so please provide
complete details; if this is considered necessary, your written consent will be obtained prior to any
information being disclosed.

Confidentiality

This is a confidential document, and will be kept by Healthwork as a confidential medical record. No medical
details will be disclosed without your written consent. Only confirmation or otherwise of your fitness with
recommendations will be sent to your employing department. Pre-placement screening is to ensure that you
are safe to perform the role, and that the role is safe for you.

Health Questions

Some roles (e.g. safety critical posts) will require a higher level of medical fitness. For such roles, we need to
ask more detailed medical questions to ensure your fitness for safety critical work. For healthcare workers,
we need to ask questions about your immune and vaccination status. We may need you to attend for a
health/vaccine assessment, if considered necessary

Based on your answers to the questions, a further assessment may considered necessary. A medical
examination may also be required for roles that have statutory medical standards, and in these cases, you
may be required to attend a health interview or medical examination. Where further assessments are
needed, we will advise you. If you are called in for a medical examination, please bring your glasses/contact
lenses with you (if worn) and details of any medication that you take.

Work History

We collect details of your previous work history as part of our occupational health assessment. Knowing
which types of occupations you have worked in previously, roles allows us to consider previous exposures to
certain hazards (e.g. noise, radiation, and asbestos). We do have a good working knowledge of which
industries/jobs are particularly hazardous. This allows us accurately assess your health related risks and
helps us ensure our pre-placement assessment of you is appropriate relative to the relevant risks.

Name: Page 1 of 5
Date of Birth: PPHA Form - Non-Clinical (Non-Verified) - HWMED 008 V3
Pre-Placement Health Assessment Form
Confidential to Healthwork

Personal Details
Title: Surname: Date of Birth:

Forenames: Previous / Maiden Name:

Address:

Post Code:

Home Phone Number: Mobile:

Email Address:
Name and address of General Practitioner:

Role Profile
Post Applied for: Permanent or Temporary:

Company/Organisation: Department/Ward/Unit:

Proposed Start date:

Have you applied for this role before? If so, please give details:

Please CIRCLE
Does the role include:
applicable
a) Manual Handling Yes No

b) Driving Yes No

c) Working with Display Screen Equipment Yes No

d) Working with vulnerable adults or children Yes No

Name: Page 2 of 5
Date of Birth: PPHA Form - Non-Clinical (Non-Verified) - HWMED 008 V3
Pre-Placement Health Assessment Form
Confidential to Healthwork

Health History Please use an additional sheet if needed.

1. Do you have/or have you ever experienced any physical illness/impairment/disability that has
affected or may affect your ability to work?
If yes, please give details below including dates:

2. Do you have/or have you ever experienced, any psychological illness/impairment/disability that has
affected or may affect your ability to work?
If yes, please give details below including dates:

3. Have you ever had an illness or disability (physical or psychological) which may have been caused by
or made worse by work in the past?
If yes please give details below including dates:

4. Are you having, or waiting for treatment (including medication) or investigations at present?
If yes please provide further details of the condition, treatment and dates below.

5. Do you have any allergies that you are aware of?

If yes please give details below:

6. Do you think you may need any adjustments or assistance to help you in your role?
If yes please give details below:

7. Do you smoke?
If yes how many per day?

8. Do you drink alcohol?

If yes how many units per week?

Name: Page 3 of 5
Date of Birth: PPHA Form - Non-Clinical (Non-Verified) - HWMED 008 V3
Pre-Placement Health Assessment Form
Confidential to Healthwork

Work Related History

Please CIRCLE
Please give full details
applicable
Have you been absent from work due to ill health
Yes No
during the past 2 years?
Have you ever left a job or been denied entry to
Yes No
work on health grounds?
Have you ever been denied a driving licence on
Yes No
health grounds?
Have you ever suffered from any work related
Yes No
health conditions?
Have you worked in a role where you have had to
Yes No
have statutory medicals for asbestos or radiation?

Please use this section to provide further details of anything you may not have been able to include above, if
necessary.
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Name: Page 4 of 5
Date of Birth: PPHA Form - Non-Clinical (Non-Verified) - HWMED 008 V3
Pre-Placement Health Assessment Form
Confidential to Healthwork

Declaration

This declaration is to be read and signed by all applicants. Please be aware this form will not be accepted
without this signed declaration.

We may need to obtain further medical information from your GP. We will do this in line with the Access
to Medical Reports Act (AMRA) and the General Data Protection Regulations (GDPR). The Access to
Medical Reports Act applies when your consent is sought to request a report from a practitioner who is
responsible for your clinical care (i.e. your GP or your specialist).

By signing this form, you are giving your consent to Healthwork requesting a medical report or medical
records from the doctor named on this form. You have the right to refuse this request. In this
circumstance, Healthwork may advise your employer only on the basis of information which is already
known.

You can request to see any information first, before it is submitted to Healthwork. If you wish to do this,
you will have 21 days in which to arrange to view the information, with your doctor. Having seen the
information, you are entitled to request that your doctor amend any part of the information that you
consider inaccurate or misleading. If your doctor does not agree to amend this, you will be able to attach
a written statement giving your views on its contents.

I declare that all foregoing statements are true to the best of my knowledge. (please tick that which
applies)

1. I understand that I may be required to attend for a health assessment.

2. I understand that further medical information may be required from my doctor if considered
necessary and therefore declare that:
 I CONSENT to the disclosure of a medical report or medical records to Healthwork
Or
 I DO NOT CONSENT to the disclosure of a medical report or medical records to Healthwork.

3.  I WISH to see the medical information before it is sent to Healthwork

Or
 I DO NOT WISH to see the medical information before it is sent to Healthwork.

4. I understand that medical details will not be divulged without my permission to any person
outside of Healthwork, but an opinion on my fitness with recommendations will be provided to
my employer.

Signature: ………………………………………………………………………………………………… Date: ……………………………….

Name: Page 5 of 5
Date of Birth: PPHA Form - Non-Clinical (Non-Verified) - HWMED 008 V3