PRE-EMPLOYMENT HEALTH MEDICAL

QUESTIONNAIRE

Name of candidate :
Position applied for :

Statement of present health

1. How would you describe your level of present health ?

EXCELLENT

GOOD

FAIR

POOR

Please explain :
2. Do you smoke ?
YES

NO

If YES, please specify quantity of cigarette per day :

3. Do you take non - prescription medicine regularly ?
YES

NO

If YES, please describe.

4. Do you take prescription medicine regularly ?
YES

NO

If YES, please describe :

5. Are you currently under the medical care of a doctor / hospital ?

YES

NO

If YES, please specify :

6. Are you currently on a waiting list for hospital treatment ?
YES

NO

If YES, please specify :

7. How often have you visited your doctor in the last year
Please specify

8. Are you currently required to wear glasses or contact lense ?

YES

NO

If YES, please specify

9. Have you ever been absent from work due to illness/injury for a continuous period in excess of two
weeks ?
YES

NO

If YES, please specify

10. Have you ever had or do you now suffer from any of the following :

- Lung / Chest Problem YES NO

(asthma, TB, pneumonia, bronchitis) Please speficy

- Heart Problem or circulatory disorder YES NO

(heart attack, high blood pressure) Please speficy

- Stomach / Pancreatic Problem YES NO

Please specify

- Kidney disorder YES NO

(kidney stones / infection ) Please specify

- Grandular Problem YES NO

( diabetes, thyroid) Please specify

-
Disorder of the nervous system YES NO
(migraine, epilepsi, stroke) Please specify

-
Psychiatric or mental health problem YES NO
( depression, nervous breakdown, anorexia) Please specify
-
Eyes, ear, nose, or throat problem YES NO
Please specify

-
Skin problem YES NO
( dermatities, psoriasis) Please specify

-
Have you ever had an operation YES NO
Please specify

-
Have you any allergies YES NO
Please specify

-
Any other accident, illness, injuries recently YES NO

Please specify

I declare that the information I have given is true and complete to the best of my knowledge and I have n withheld
any material facts. I understand that I am responsible for accuracy of my statement and that if
I wilfully suppress any information that I risk the loss of appointment

Signed Date