NEW EMPLOYEE MEDICAL QUESTIONNAIRE - CONFIDENTIAL
The purpose of the questionnaire is to see whether you have any health problems that could affect your
ability to undertake the duties of the post you have been offered or place you at any risk in the workplace.
We may recommend adjustments or assistance as a result of this assessment to enable you to do the job.
Our aim is to promote and maintain the health of all people at work. Before health clearance is given for
employment you may be contacted by the Healthier Business UK Ltd and may need to be seen by an
occupational health advisor or physician. Your record will be held on file for a short period of time and may
be subject to audit. Your file may also be used to cross referenced should be registered on our system by
one employer.
Personal Information
Title Surname First names DOB
Home Tel: Work Tel: Mobile:
Home Address: GP Address:
Medical History
All staff groups complete this section Yes No
Do you have any illness/impairment/disability (physical or psychological) which may affect
your work?
Have you ever had any illness/impairment/disability which may have been caused or made
worse by your work?
Are you having, or waiting for treatment (including medication) or investigations at present?
If your answer is yes, please provide further details of the condition, treatment and dates
Do you think you may need any adjustments or assistance to help you to do the job?
If you have indicated yes to any of the above question’s you must provide further details, failure to do so
will result in the form been returned/rejected.
Additional Information
(If you have answered yes to any question above please provide additional information
below)
Tuberculosis
Clinical diagnosis and management of tuberculosis, and measures for its prevention and Yes No
control (NICE 2006)
Have you lived continuously in the UK for the last 5 years?
If you answered NO to the above, please list all of the countries that you have lived in/visited over
the last 5 years, including duration of stay and dates.
Have you had a BCG vaccination in relation to Tuberculosis?
If you answered yes please state when Date
Do you have any of the following Yes No
A cough which has lasted for more than 3 weeks
Unexplained weight loss
Unexplained fever
Have you had tuberculosis (TB) or been in recent contact with open TB
Chicken Pox or Shingles
Have you ever had chicken pox or shingles
Yes No Date
Immunisation History
Have you have any of the following immunisations Yes No Date
Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)
Polio
Tetanus
Hepatitis B (If Yes is ticked please give dates below)
Course: 1 2 3
Boosters: 1 2 3
Additional Information
(If you have answered yes to any question above please provide additional information
below)
Proof of Immunity (Please send the following)
Varicella You must provide a written statement to confirm that you have had chicken
pox or shingles however we strongly advise that you provide serology test
result showing varicella immunity
Tuberculosis We require an occupational health/GP certificate of a positive scar or a record
of a positive skin test result (Do not Self Declare)
Rubella, Measles Certificate of “two” MMR vaccinations or proof of a positive antibody for
Rubella and Measles
Hepatitis B You must provide a copy of the most recent pathology report showing titre
levels of 100lu/l or above
Proof of Immunity (Please send the following) EPP Candidates Only
Hepatitis B Evidence of a negative Surface Antigen Test. Report must be an identified
Surface Antigen validated sample. (IVS)
Hepatitis C Evidence of a negative antibody test. Report must be an identified validated
sample. (IVS)
HIV Evidence of a negative antibody test. Report must be an identified validated
sample. (IVS)
Exposure Prone Procedures
Will your role involve Exposure Prone Procedures Yes No
Declaration
I declare that the answers to the above questions are true and complete to the best of my knowledge and
belief. I also give consent for the Healthier Business UK Ltd to make recommendations to my employer.
Name Signature Date
