Medical Form

Please fill the form out below regarding your medical history

First name

Last name

Birthday

Day

Month

Year

Position

Have you ever...

Had an operation?

Been seriously injured?

Had a serious physical or mental illness?

Received in patient treatment for a physical or mental illness?

Been refused or dismissed from employment for a health condition?

Received a disability pension?

Had a disability?

Been made ill by your work?

Been refused a driving license because of ill health?

So that we can assist you with your job role, if answered YES to any of the above, please provide further details

Do you suffer from or have you ever had...

Heart trouble?

Lung disease

Headaches or migraines?

Diabetes?

High or low blood pressure?

Allergies?

Joint problems (including arthritis)

Asthma

Muscular skeletal problems

Skin complaints (including eczema)

Mobility problems

Cancer

Fits, blackouts or neurological problems

Depression or anxiety

Kidney or bladder disorder

Stroke

Shortness of breath

Stomach or bowel problems

Long term or ongoing sight problems

Long term hearing problems

Any other condition, impairment or illness which affects your daily life on a long term basis

So that we can assist you with your job role, if answered YES to any of the above please provide further details

Are you currently

Pregnant?

Taking any prescribed medication

Under the care of a doctor or any other medical professional?

If YES, please provide details

Do you smoke

On average, how many units of alcohol do you drink per week?

I understand that the above information is to determine my fitness to carry out the job role and if any reasonable adjustments may be necessary to allow me to do so.

To the best of my knowledge and belief, the information given above is correct. I understand that if I am appointed and if the information I have provided is incorrect or misleading, I may be liable to dismissal, or withdrawal of an offer of employment.

I confirm I have read the above information and filled out the form to the best of my knowledge