Pre-Employment Health Questionnaire

PLEASE READ THE WHOLE OF THIS FORM BEFORE YOU BEGIN TO COMPLETE IT A pre-employment health assessment helps to protect your own and others health and safety by assuring that you are fit for the post you have applied for. The questionnaire asks you to provide details of your health. Please do not be concerned if you answer ‘yes’ to a lot of questions. This does not necessarily mean you are unfit for a job. Rosebank Private Medical Services are an Occupational Health provider and we are responsible for safeguarding the privacy of your information. We fully comply with the provisions of the General Data Protection Regulation (GDPR) with regard to ‘personal data’ within our control. Any information you provide will remain confidential.

Last Updated: 13/09/2019

Job Details







Personal Details

















Duties of Post




Medical History

Please answer ALL of the questions below. If you answer YES to any of the questions you will need to give further details in section 5. The disability Discrimination Act 1995 defines a person with a disability as “A physical or mental impairment which has a substantial adverse long term effect on his or her ability to carry out normal day top day activities”.




Section 1 - Current and Past Health

Please answer ALL of the questions below. If you answer YES to any of the questions you will need to give further details in section 5. The disability Discrimination Act 1995 defines a person with a disability as “A physical or mental impairment which has a substantial adverse long term effect on his or her ability to carry out normal day top day activities”.












Section 2 - Do you currently have or have ever suffered from any of the following medical conditions?

Please answer ALL of the questions below. If you answer YES to any of the questions you will need to give further details in section 5. The disability Discrimination Act 1995 defines a person with a disability as “A physical or mental impairment which has a substantial adverse long term effect on his or her ability to carry out normal day top day activities”.
















































Further Details of Medical Conditions

If you have ticked yes to any of the questions above please give further details below, include date(s), frequency, duration, what treatment was given and by whom e.g. hospital/GP. Please include the appropriate question number. This will help clarify the significance or otherwise of a ‘yes’ answer.









Immunisations

Have you been immunised against the following -please email a copy of immunity report, which you can obtain from your GP






Immunisation record


Declaration

I declare that all of the above statements and information is true to the best of my knowledge




Further Information