Pre Employment Health Declaration Form WORK RELATED HEALTH HISTORY WYES, give details and dates . Have you ever left, or been denied a job on heaith grounds? NO HEALTH RELATED HISTORY Do you nave or have you fal in tie past: IEYES, give detalls and dates '@ Conditions of the heart? High blood pressure? Heart attacks? Angina? YES b, Migraine or persistent headaches? . Eye conditions? Restricted vision? Glaucoma? Iritis? Any other condition? 4. Ear conditions? Restricted hearing? Tinnitus? Ear infections? e. Alcohol or drug problems? Problems related to aloohot or drug usage or dependency? £. Mental liness andior stress related problems? Nervous breakdown? Mental fatigue? Amicty? Depression? Panic attacks? Significant sleep disturbance? Stress related problems? Eating disorders? Self harm? Any other conditions? YES 9. Have you consulted a specialiet or needed any ‘operations other than atready stated? YES fh Have you spent any time in hospital other than already stated? 1 Are you receiving medical treatment al the present time? YES j. Do you take any regular medication? k. Have you any other health Issues that have not been mentioned above or about which you would like to provide further details? L. Are you pregnant ? if yes, how many months 7 DECLARATION — To be completed by applicant | deciare that all the above deciaration is accurate and to my best knowledge. if I'm found providing false info, the company has the right to terminate my employment. Name (BLOCK CAPITALS):