Employee Health Examination Questionnaire

Keeping our employees safe and healthy is important to us, so please complete this questionnaire to help us
do so whilst you are at work. Any information provided in this form is strictly private and confidential and
will only be shared under GDPR guidelines.

The Disability Discrimination Act defines a disability as a physical or mental impairment which has a substantial
and long-term adverse effect on your ability to carry out normal day-to-day activities.
Do you consider yourself to have a disability?
Please state the nature of the disability and any adjustments to be made to carry out this role?

Please tell us about any other medical conditions that you have or things we need to know about to keep you
safe and healthy whilst at work and any adjustments we should consider making to help you whilst at work?

Please tell us about any medication prescribed by a Doctor that you are currently taking, or you know you will
be taking during your employment.

Please tell us if you are currently under the care of a Doctor / Consultant / Specialist. Please give details.

Has your work ever been limited, or have you had to take significant time off work due to your health? Please
give details.

By signing below, you agree to the best of your knowledge and belief you are in good health and not knowingly
incapable of engaging in work with J & E Hall. You also agree to notify J & E Hall of any change in health which
may affect your ability to undertake your job safely, or so we can keep you safe at work. You also agree that
this information can be shared in order to keep you safe at work (for example with nominated first aiders, or
with medical professionals in emergency situations).
Name

Signature

Date