Health Questionnaire

Site/Location: Position Offered:

Please complete and return this questionnaire with your recruitment paperwork after an offer of employment has
been made. The information given will remain confidential. Tick Yes or No Boxes as Applicable.

Full Name:

Occupational History
1. Has your employment ever been terminated on the grounds of ill health or for reasons connected to your health?
No
Yes Please give details:

2. Approximately how many days or weeks sickness absence have you taken in the last 12 months?

Medical Information
1. Do you have any allergies/reactions or intolerances to any food / drink / medication / materials etc?
No
Yes Please give details:

2. Do you have any mental or physical condition or disability that you think we should be aware of or which may
affect your employment?
No
Yes Please give details:

3. Are you currently taking any medication for any condition of which we should be aware?
No
Yes Please give details:

4. Do you suffer from any reoccurring/regular illness/medical problem?

No
Yes Please give details:

5. For Health & Safety reasons, please state if you are pregnant or have recently given birth:
No
Yes
6. Have you been admitted to hospital for any serious illness or operation over the past 3 years?
No
Yes Please give details:

Please turn over.

7. Are you currently suffering, or have you ever suffered from any of the conditions listed below:
Back / Neck Problems No Yes
Contagious skin conditions No Yes
Depression / Anxiety No Yes
Diabetes No Yes
Fits / Blackouts / Epilepsy No Yes
Hearing / Sight Problems No Yes
Hepatitis No Yes
Joint Problems / Arthritis No Yes
Mobility problems No Yes
Stress Reaction No Yes
If you have answered Yes to any of the questions above please give further details and approximate dates where relevant.
This is particularly important where you have a qualifying disability under the Equality Act 2010 as it will enable us to identify
what, if any, reasonable adjustments can be made:

Additional Information
1. Please provide details of who to contact in an emergency at work:

Name: Relationship:

Day time telephone: Evening:

2. The UK National Immunisation Programme included vaccination against Mumps, Measles, Rubella, Tuberculosis
(recently withdrawn), Polio and Tetanus. We recommend you are immunised against these infections.
All employees who work closely with pupils/residents in our care are strongly advised to have Hepatitis B immunisation.

Your signature: * Date:

*In signing this questionnaire you confirm that all information provided is true and accurate to the best of your knowledge.
You also accept that in the event of being employed, if it is subsequently shown that relevant medical information has not
been disclosed by you, or has been misleading or false, then your employment may be terminated in line with the formal
disciplinary procedure. If you are yet to start employment then any job offer may be withdrawn.
Failure to complete all sections fully or any delay in completing and returning this form may result in a delayed start date.
It is imperative to notify a Manager should there be any significant changes in your health status from the date of signing
this questionnaire.
If further information is required from your G.P or specialist, your written consent will be requested first.

Thank you for taking the time to complete this form.