Night Work Health Questionnaire

The purpose of this questionnaire is to ensure that you are suited to working at night.
All information you provide will be kept confidential.

1. Surname:............................................................................................................
2. Forename(s):…………………………………………………………………………..
3. Sex: Male Female
4. Date of Birth:…………………………………………………………………………..
5. Permanent Address:…………………………………………................................
............................................................................................................................
............................................................................................................................
6. Job Title………………………………………………………………………………..
7. National Insurance Number……………………………………………...................
8. Company Number…………………………………………………………………….

Do you suffer from any of the following health conditions?

• Diabetes NO
• Heart or circulatory disorders NO
• Stomach or intestinal disorders NO
• Any condition which causes difficulties sleeping NO
• Chronic chest disorders, especially if night time NO
symptoms are troublesome
• Any medical condition requiring medication to a strict NO
timetable
• Any other health factors that might affect fitness at work NO

If you have answered “Yes” to the above question you may be asked to see a
doctor or nurse for further assessment.

I, the undersigned, confirm that the above is correct to the best of my knowledge

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

Kings Court, 17 School Road, Hall Green, Birmingham B28 8JG. HR 08 - Revision 4
Tel: 0121 777 7756, Email: hr@primess.co.uk, Web: www.primess.co.uk 01/07/2023
Company Registration No: 10735034 Page 1 of 1