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Health Questionnaire for Employment

1) The document is a health questionnaire for a job applicant containing questions about any past or current health conditions. 2) It asks about conditions like tuberculosis, heart issues, mental health, skin conditions, accidents, operations, and communicable diseases. 3) It notes that satisfactory medical reports may be required and that health could affect employment, attendance, or job performance.

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james pownall
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77 views3 pages

Health Questionnaire for Employment

1) The document is a health questionnaire for a job applicant containing questions about any past or current health conditions. 2) It asks about conditions like tuberculosis, heart issues, mental health, skin conditions, accidents, operations, and communicable diseases. 3) It notes that satisfactory medical reports may be required and that health could affect employment, attendance, or job performance.

Uploaded by

james pownall
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

INSERT LOGO HERE

HEALTH QUESTIONNAIRE
PRIVATE & CONFIDENTIAL

Ref. no:

Name:

Date: / /

Position offered:

(subject to satisfactory health checks)

If the answer is yes to any of the questions on this form, please give full details in the space
provided of the dates, duration and outcome of the illness or condition. If we have any concerns
about your fitness for work, employment will be subject to satisfactory medical reports.

Additional information to Yes


Have you ever had Insert Yes/No response

!
Tuberculosis, asthma, bronchitis
or chest problems?

!
Chest pain, heart condition or
raised blood pressure?

!
Blackouts, fits or attacks of
giddiness?

!
Depression, mental illness or
nervous breakdown?

!
Rheumatism or arthritis?

!
Back trouble?

!
Typhoid or paratyphoid?

!
Digestive or bowel disease?

!
Diabetes, thyroid or other gland
trouble?

!
Bladder or kidney trouble?

!

Dermatitis or skin trouble?


Varicose veins?

!
A d d i t i o n a l i n f o r m a t i o n t o Ye s
Have you ever had Insert Yes/No response


Any other accident, operation or
illness?


Have you any reason to believe
you may be infected with any
communicable disease?


Any other current or recent
medical condition or treatment
which might affect your
attendance or performance at
work?


Do you intend to work night
duties on a regular basis?


Has any illness or medical
condition prevented you from
attending work on your normal
duties or activities for more than
one week during the past year?
If yes, please specify.


Do you have any physical or
mental impairment which has a
substantial and long term effect
on your ability to carry out day to
day activities? If yes, please
specify any special adjustments
required in relation to work.


Do you smoke?


How many units of alcohol do
you drink per week?
(one unit = 1 middy beer =
1 glass wine = 1 shot of spirits)

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