Strictly Private and Confidential

The primary purpose of this health declaration is to assist in ensuring that no employee is placed in an environment
or given tasks that will result in physical or mental harm. It is not the intention of the health declaration to deny a
person employment solely because of disability, illness or injury. The health declaration is required so that we may
take the appropriate and reasonable action to ensure the employee’s health, safety, and wellbeing.
You are required to disclose to the HR Department any pre-existing illness, disease, injury or condition that you
have suffered or continue to suffer of which you are aware and could reasonably be expected to foresee, and could
be affected by the nature of your employment.
Should any circumstances change that may affect your capacity to perform the inherent requirements of the position
you have undertaken, you are obligated to inform the HR Department immediately.

Name: Position:

Do you have any of the following Answer

Are you pregnant Yes ☐ No ☐

Allergies Yes ☐ No ☐

Frequent headaches or migraine's Yes ☐ No ☐

Low or high blood pressure Yes ☐ No ☐

Any other blood condition or disorder Yes ☐ No ☐

Skin disorders such as eczema, psoriasis or skin rashes Yes ☐ No ☐

Visual disturbances or defects such as blurred vision Yes ☐ No ☐

Hearing or ear issues Yes ☐ No ☐

Balance problems, vertigo, unexplained dizzy spells Yes ☐ No ☐

Fits, blackouts, epilepsy, fainting or unexplained periods of unconsciousness Yes ☐ No ☐

Nervous system diseases such as strokes, neuritis or multiple sclerosis Yes ☐ No ☐

Lung issues such as pneumonia, emphysema, asthma or bronchitis Yes ☐ No ☐

Unexplained breathlessness, chest pain, angina or heart disease Yes ☐ No ☐

Metabolic conditions such as thyroid/adrenal gland disease or diabetes Yes ☐ No ☐

Rheumatism, Arthritis or similar Yes ☐ No ☐

Infectious diseases Yes ☐ No ☐

Stress related problems, anxiety problems, depression or mental breakdowns Yes ☐ No ☐

Any other medical conditions, illness or disease Yes ☐ No ☐

Do you have, or have you ever had, any kind of back, joint/limb or muscle Yes ☐ No ☐
problem?
If you have answered “Yes” to any of the above, please give details:

Are you taking any type of medication?

If yes, please specify:

Declaration

I declare that all the answers given in the above Pre Employment Health Declaration are complete, true and I have
not omitted any information. I understand this would be sufficient grounds for serious action to be taken against
me, including dismissal.

Signature: Date: