Health Questionnaire

Please complete the questionnaire below. The information is required with your own interests in mind. All
information given will be treated in the strictest confidence but will be forwarded to our First-Aiders upon
your appointment, and kept on your personnel file. If you require further information, please contact HR

Please provide any details

necessary in the space below
Do you have any physical or mental impairment No Yes
that could be classed as a disability under the
Disability Discrimination Act 1995? If yes,
please give details.

Have you consulted a doctor about your health No Yes Skin surgery, depression and anxiety
during the past 12 months? If yes, please give
details.

Have you been off work continuously for more No Yes

than 1 month during the last 5 years? If yes,
please give details.

Have you ever been refused or dismissed from No Yes

employment due to health reasons? If yes,
please give details.
How many days absence have you had through
illness over the last 12 months?

Are you able to carry out physical work such as No Yes

lifting, bending, carrying, standing for long
periods of time? If not, please give details.

Have you ever had any operations requiring No Yes

hospital admission for 5 days or more? If yes,
please give details.

Is your eyesight normal (with glasses or contact No Yes

lenses if worn)?
Is your hearing normal? No Yes
Medical history

Please complete below. It is in your best interests to give as much detail here as possible. All information will
be treated in the strictest confidence but will be forwarded to our First-Aiders where appropriate and kept on
your personnel file. Please use the space provided (continue on a separate sheet if necessary) to detail any
medication you take regularly (including inhalers and syringes) and indicate whether you carry a warning card,
bracelet or epi-pen etc.

Y/N Regular medication / prescribed drugs

Diabetes (Hypoglycaemia or Hyperglycaemia) N

Heart trouble / angina N

Asthma (or other breathing conditions) N

Epilepsy N

Raised blood pressure N

Fainting attacks or giddiness N

Peptic, gastric or duodenal ulcer N

Kidney trouble or urinary infection N

Menstrual/Prostate problems Y Naproxen

Musculoskeletal conditions, including back N

problems
Arthritis N

Repetitive strain injury Y

Anxiety, depression or other nervous complaint Y Sertraline

Migraine or severe recurring headaches N

Dyslexia N

Do you suffer from any other illness/condition N

(whether you are currently receiving medical
treatment or not)? Please provide details

Please give details of any allergies

To the best of my knowledge and belief the information given above is correct. I understand that if I have
willingly given incorrect information, I may be liable to dismissal.

Signature: Christina S Date: 11/5/21