Department of Social Welfare and Development

FO1-HRWS-007
Field Office 1 REV 00 / 26-04-2021
Quezon Avenue, City of San Fernando, La Union

Staff Declaration of Health

As of _________________

Employee Number: __________

The purpose of this Health Declaration is to assess what reasonable work adjustments you may require in order
to undertake certain duties. The information you provide will remain confidential to the Office and will be part of
Employee Health Record. It may also be used for Risk Classification of Staff and in determining Fitness to Work.
1. Personal Details
Family Name: First Name: Middle Name:

Permanent Address: (Brgy., City/ Municipality, Province) Sex: (M/F)

Residential Address: (Brgy., City/ Municipality, Province) Civil Status:

Date of Birth:(MM/DD/YYYY) Place of Birth (City/Municipality,

Province)

Email: Mobile Number:

Person to Contact In Case of Emergency:

Name: Contact Number:

Address Relationship:

2. Position/ Designation

Official Station (Division / Section / Unit / RPMO / P/C/MOO):

3. Work Related History Yes No If “Yes”, Please give details:

(Date/Duration; Diagnosis/Condition,
etc.)
Have you been absent from work due to ill health
during the last 12 months?

Have you ever suffered from any work related

health conditions, injuries or accidents throughout
employment?
4. Health History:
Do you have or have you had in the past: YES NO If “Yes”, Please give details:
(Condition; Date when
Diagnosed/Occurred; Was it Resolved,
In Remission or Recurring)
Conditions of the lungs?
Asthma/bronchitis/pneumonia/tuberculosis/other
chest complaints/coughing up blood/shortness of
breath?
Conditions of the heart?
High blood pressure/heart attacks/chest pains/
ischemic or coronary heart disease, heart valve
disorders, irregular heartbeats?
Nervous system disorder?
Blackouts/epilepsy/muscular weakness/paralysis?
Migraine, vertigo, or persistent headaches?
Conditions of the digestive system?
Irritable bowel syndrome / liver complaints /
jaundice / colitis / gastric / duodenal ulcer?
Conditions of the bones, joints and limbs?
Arthritis/rheumatism/back problems/neck and
shoulder problems/sciatica/upper limb
disorder/tennis elbow, carpal tunnel syndrome, or
any other musculoskeletal conditions?
Allergies?
Including allergies to drugs/ chemicals, animals and
particles (dust/pollen)
Skin conditions?
Eczema/dermatitis/psoriasis/recent infection/skin
cancer?
Gland trouble?
Diabetes/ Thyroid – overactive/underactive?
Eye conditions?
Restricted vision/glaucoma/iritis/any other
conditions
Ear conditions?
Restricted hearing/tinnitus/ear infections?
Alcohol or drug problems?
Problems related to alcohol or drug usage or
dependency?
Smoking (or using e-cigarettes/ vape) in the last 12
months?
Mental illness and/or stress related problems?
Nervous breakdown/mental
fatigue/anxiety/depression/panic attacks/significant
sleep disturbance/stress related problems/eating
disorders/self harm/any other similar conditions?
Have you consulted a specialist or need any
operations other than already stated?
Have you spent any time in hospital other than
already stated?
Have you consulted a doctor for other health
conditions not mentioned above in the last 12
months?
Are you receiving medical treatment at the present
time?
Do you take any medication? (Enumerate)
Do you have existing disability or physical
limitations?
Do you have any other health issues that have not
been mentioned above or about which you would
like to provide further details?

DECLARATION FROM STAFF

I declare that the information given within this declaration of health is true and complete to the best of my
knowledge. I understand and accept that I may be required to attend for an Occupational Health Assessment.

I understand and accept that further medical information may be requested from my personal doctor if considered
necessary.

I understand that making false statements or failure to declare health problems may lead to disciplinary action, up to
and possibly including termination based on existing Office rules.

I agree to update this declaration of health on an annual basis.

_________________________________ _____________________
Printed Name & Signature of Staff Date