New Employee Health Questionnaire

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New Employee Health Questionnaire

Guidance notes; please read carefully. This new employee health questionnaire gives us information which helps us to: Identify any medical condition which could pose a safety risk to you, your colleagues, patients or members of the public. Check that you are not particularly vulnerable to any hazards that your job may contain. The medical details you disclose on this form remain confidential to the HR Department and will not be disclosed to anyone else without your explicit consent.

PERSONAL DETAILS

Name(Required)

Title First Last Previous Names (if applicable)

Email(Required)

Enter Email Confirm Email

Contact Number

Date of Birth

MM slash DD slash YYYY

Home Address

MEDICAL HISTORY

It is important that you give a true and full account of any medical problems when asked. If the answer to any of the following questions is “Yes” please give details.

Do you have any illness, impairment, disability (physical or psychological) which may affect your work?(Required)

Yes

Have you ever had any illness, impairment or disability which may have been caused or made worse by your work?(Required)

Yes

Are you having or waiting for treatment (including medication) or investigations at present?(Required)

Yes

Do you need any specific aids or adaptations to assist you at work whether or not you have a disability, including any hearing or visual aids?(Required)

Yes

Do you have any allergies which may be made worse by work e.g. latex?(Required)

Yes

Are you receiving any treatments or ongoing medication?(Required)

Yes

Do you have any allergies?(Required)

Yes

Have you lost time at work/college/school due to illness in the last 2 years?(Required)

Yes

Have you ever suffered an injury at work requiring time off from work?(Required)

Yes

Where you ever discharged from previous employment on medical grounds?(Required)

Yes

Have you had any of the following:

Arthritis / Rheumatism(Required)

Yes

Mental Health Problems(Required)

Yes

Alcohol or drug related abuse(Required)

Yes

Anaemia or blood disorder(Required)

Yes

Asthma(Required)

Yes

Epilepsy, head injuries, vertigo(Required)

Yes

Ear / Eye conditions(Required)

Yes

Diabetes(Required)

Yes

Skin conditions eg. Dermatitis, eczema(Required)

Yes

Bronchitis, persistent cough or wheeze(Required)

Yes

Difficulties with walking / bending(Required)

Yes

Back injury / problems(Required)

Yes

Neck injury / problems(Required)

Yes

Any other health related problems?(Required)

Yes

Heart / Liver or Kidney problems(Required)

Yes

Cough which lasted more than 3 weeks(Required)

Yes

Unexplained weight loss(Required)

Yes

Intermittent fever with night sweats(Required)

Yes

Investigation for Tuberculosis(Required)

Yes

Have you been diagnosed with COVID? If so when? Have you had any lasting symptoms and if so, what?(Required)

Yes

A close family member / friend with whom you share a home diagnosed with TB(Required)

Yes

Have you lived continually in the UK for the last 5 years?(Required)

If no please list all the countries you have lived in for over a month during this time and advise if you have had a chest x-ray report since arriving in UK?

Yes

Please give further information on any YES answers from the above questions.

DECLARATION

Before signing this declaration please ensure you have answered all the questions as instructed providing further details as required. Please ensure the consent form is also signed and fully completed.(Required)

1. I acknowledge that my personal details will be stored both electronically and manually by the HR Department in accordance with the Data Protection Act 2018. 2. If I have any concerns about how this information is handled I will contact the HR Manager. 3. I declare that the information provided by me in this entire form is true and complete to the best of my knowledge and belief. 4. I understand that if any recommendations to my employer are necessary as a result of this new employee health assessment, the HR Manager will discuss the recommendations with me before making them to my employer. 5. I give consent to the HR Manager to make recommendations to my employer; I do / do not wish to see a written copy of the recommendations before my employer. (please delete as appropriate) Agree? (Required)

Yes

Date(Required)

Consent

By using this form, you agree with the storage and handling of your data by this website.