Date of Birth
Contact Telephone Number
The purpose of this questionnaire is to help us make an assessment of your health in relation to your employment. The information given will not be disclosed to anyone without your permission. Please answer the following as accurately as you can.
Do you presently, or have you in the past suffered from any of the following?
Anaemia or Blood DisorderDiabetes or Thyroid troubleHernia or other RuptureDeafness or Ear DisorderDermatitis or Skin ConditionAllergiesEye ProblemsColour BlindnessAngina or a Heart AttackOther Heart problemsHigh Blood PressureCirculation problems or Varicose VeinsEpilepsy, Fits, Faints or CollapsesHead Injury or Skull FractureMigraine or Recurrent HeadachesWeakness of the Arms or LegsBackache, Back Injury or ProlapseNeck Injury or PainArm or Leg InjuryArthritisCystitis or Kidney DiseaseNervous Breakdown, Mental Illness or DepressionJaundice or Liver DiseaseDrug or Alcohol AddictionAsthma, Bronchitis or Chest DiseaseHeartburn or Ulcer DiseaseWomen only: Any gynaecological disorder
If yes to any of the above please give details for each
Have you ever had two weeks or more off work due to illness?
If yes please give details:
List here any medication you take on a regular basis, which has been prescribed by your Doctor
Are you currently waiting for any investigation or treatment from your GP or another Doctor?
Do you have any of the following physical difficulties or limitations affecting you?
SittingRising from sittingStandingWalking up/climbing down stairsBending or kneelingReachingLifting/CarryingWalkingManual DexterityVisionHearingSpeechSkinBreathingAlertnessWork at height
Thank you for taking the time to complete this questionnaire!
I declare that the answers given in this questionnaire are true to the best of my knowledge and belief.
I consent to the results of this surveillance being shared with my employer:
If consent to write to your employer is withheld, this completed questionnaire will be held in your occupational health file but no further action will be taken.
Employee signature (type name to sign)