STRICTLY CONFIDENTIAL

PRE-EMPLOYMENT HEALTH QUESTIONNAIRE

ABOUT YOUR HEALTH……… The answers to these questions will give us some understanding of
whether you will be capable of undertaking the position you have been offered. Answering yes to any of the
questions does not mean you will not be able to work for Mott MacDonald in the India, however we will need
further details in order to asses what further steps i.e. reasonable adjustments, if practically possible, to suit
your particular needs. Should you be employed by MM, these details will remain on your personal file so
that we may be aware of any medical conditions that may be prevalent should you become ill at work or be
considered for transfer to a new site or to a new type of work.

Although you should record all health issues, only aspects of health relevant to the job applied for will be
taken into account.

Position Offered Trainee Engineer (Civil/Structure)

SECTION A APPLICANT DETAILS

Title Mr. First name Manankumar Last name Shah

SECTION B MEDICAL DETAILS

1 How many days have you been absent from work due to illness in the last 2 years?
12 days

2 If you have had any periods of absence from work due to illness which lasted for NO
more than two weeks in the last two years please give details:

3 Do you have any disability which you consider would impact on your performance in NO
the job for which you are applying? If YES please give details

4 Are you at present receiving medical treatment/taking any regular medication? If NO

YES please give details below:

5 Have you ever been considered medically unfit for any previous employment, life NO
insurance policy, armed forces or for a driving licence? If YES please give details
below:

6 Has any abnormality ever been detected as a result of a chest x-ray? If YES please NO
give details below:

1
7 Are you at present suffering from, or have you suffered from in the last five years,
any of the following?
Defective vision (not corrected by glasses or contact lenses) NO
Persistent cough / spitting blood NO
Bronchitis / Emphysema NO
Recurring stomach/bowel trouble NO
Tuberculosis NO
Recurring bladder trouble NO
Asthma NO
Pneumonia / Pleurisy NO
Fits / blackouts / fainting attacks / Epilepsy NO
Back strain or trouble/pain NO
Breathlessness NO
Hernia rupture NO
Diabetes NO
High blood pressure NO
Anxiety or depression, schizophrenia or other mental health issues NO
Rheumatic fever NO
Drug/alcohol problems/dependence NO
Stroke NO
Epilepsy NO
Ear trouble/deafness NO
Chest disease/pain NO
Varicose veins NO
Serious injury/accident NO
Severe hay fever or any other allergy NO
Muscle or joint trouble NO
Arthritis/knee or hip replacement NO
Recurring headaches or migraines NO
Skin trouble/rash/dermatitis/eczema/psoriasis or any other skin condition NO
Typhoid / Dysentery NO
Kidney disease NO
Stress NO
Heart Disease NO
Bowel trouble NO
Serious illness/operation NO
Head injury/Concussion/Giddiness NO
Fear of enclosed/open space NO
Thrombosis/ leg or foot problem NO
Colour blindness NO
Any other significant infection NO
If you have answered YES to any of the above, please give brief details, including
dates where possible below (continue on a separate sheet if necessary)

8 Have you had any periods of continuous illness of 2 weeks or more during the last 5 NO
years? If YES please give details. How many periods of absence does the total

2
 number of days taken total?

9 Please indicate if you have any disabilities which affect:

Standing NO
Manual handling NO
Walking NO
Use of your hands NO
Climbing stairs NO
10 Are you aware of any health problems, symptoms or injuries associated with your NO
current/past job(s)?
If YES please give details

11 Have you ever had to change jobs or work assignments because of a health NO
problem or injury?
If YES please give details

12 Have any types of work caused you significant strain in your limbs or back before? NO
If YES please give details

13 Have you had to stay in hospital during the last 5 years? NO

If YES please give details

14 Do you expect to ask for a leave of absence for health reasons in the near future? If NO
YES please give details

15 Do you smoke? NO
If YES, please state how many cigarettes per day/shisha pipes per week
16 Is there any information regarding your health which is not given above, but should NONE
be taken into account? If none, please write ‘NONE’.
If YES please give details

SECTION C DECLARATION
I hereby declare that all of the above answers are to the best of my belief, true and complete and I have not
withheld any information which would help in determining my medical fitness for the position for which I am
being considered.

I understand that failure to disclose any relevant information on this form may lead to my employment
being terminated.

Name: Shah Manankumar Bhaveshbhai Signature:

Date: 09/06/2022

If it is necessary to obtain a medical report from your Doctor or other Medical Advisor you will be notified in
writing.
Thank you for completing this form