Pre-employment Medical Questionnaire

Position Applied for:

Personal Details:

Full Name

Address

Age & date of birth

Name & Address of GP

Occupational History:

Has your employment ever been terminated on the grounds of ill health?         

Approximately how many days/weeks sickness have you had in the past 12 months?         

Medical History:

Your height?

Your weight?

Amount of units of alcohol consumed weekly?

Are you a smoker?

Are you currently under the care of a doctor or medical professional?

    

Are you currently suffering from or have suffered from any of the illnesses listed below:

Heart Trouble
Lung Disease
Stomach/bowel trouble
Jaundice/hepatitis
Joint Problems
Diabetes
Allergies
Headaches/Migraines
Severe stress reaction
Serious accident
High blood pressure
Asthma
Hernia or rupture
Kidney/bladder disorder
Back/neck problems
Fits/blackouts/epilepsy
Depression/anxiety
Hearing/sight problems
Skin problems
Surgical operations

If you have answered ‘yes’ to any of the questions above, please give details and approximate dates where relevant:

I hereby declare that the information given is full and true to the best of my knowledge.  I understand that if, at a later date, it is discovered that I have knowingly withheld medical information, disciplinary action may be taken against me, which may include dismissal.

Name:

Date: