Jordan James Ltd

Medical Questionnaire

Surname:
Forename:
Address:

National insurance National Health

number: Service number:
Name and address of
own doctor:

Please answer all the following questions. Circle your answer, Yes or No and provide additional
information where required.

Questions
1 Do you have any physical or mental impairment that could be Yes No
classed as a Disability Discrimination Act 1995?
2 Have you ever received compensation or a disability pension? Yes No
3 Are there any medical reasons why you should not do shift Yes No
work outside your normal working hours?
4 Are you able to carry out strenuous physical work including Yes No
climbing ladders, working from scaffolding, bending, lifting and
carrying?
5 Have you ever had to give up any previous job for medical Yes No
reasons?
6 Have you been off work continuously for more than a month Yes No
during the last five years?
7 Have you ever had any operations requiring hospital admission Yes No
for five or more days?
8 Is your eyesight normal (with glasses if worn)? Yes No
9 Is your hearing normal? Yes No
10 (a) Do you regularly take tablets or medicine? Yes No

(b) If yes, what do you take?

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 Jordan James Ltd
Medical Questionnaire

11 Have you ever had any of the following?

Diabetes Yes No
Tuberculosis Yes No
Angina Yes No
Any other heart trouble Yes No
Raised blood pressure Yes No
Peptic, gastric or duodenal ulcer Yes No
Indigestion for more than one week Yes No
Back trouble, lumbago, sciatica, ‘slipped disc’ Yes No
Epilepsy, recurring blackout or fits Yes No
12 Have you had any of the following during the past five years?
Bronchitis, asthma, pneumonia Yes No
Dermatitis, eczema or any other skin trouble Yes No
13 Do you suffer (or have suffered) from any of the following?
Migraine or severe recurring headaches Yes No
Anxiety, depression or any other nervous complaint Yes No
Fainting attacks or giddiness Yes No
Ear trouble, discharging or infected ear Yes No
Kidney trouble or urinary infection Yes No
14 If you have circled any answer as Yes for questions 1 to 13, please give very brief details
below:

15 Have you ever had any other serious illness? If yes, please give very Yes No
brief details below.

16 Have you consulted a doctor about your health during the past 12 Yes No
months? If yes, please give very brief details below.

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 Jordan James Ltd
Medical Questionnaire

I am willing to undergo a medical examination if required and i declare that the information I have
given on this form is complete and correct to the best of my knowledge. I agree that the Employer’s
doctor may consult my own doctor about any of the information given on this form.

Note: any false, incomplete or misleading statements may lead to dismissal.

Employee’s signature (below): Date:

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Data protection

Information from this application may be processed for the purposes registered by the Employer
under the Data Protection Act 1998. Individuals have, on written request and on payment of a fee od
£10, the right of access to personal data held about them.

For the purposes of compliance with the Data Protection Act 998, I hereby give my consent to Jordan
James Ltd retaining the information on my personnel file. I understand that the information will be
stored in accordance with the Data Protection Act 1998.

Employee’s signature (below): Date:

[ ] [ ]

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