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Health Medical Form

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Health Medical Form BUK.SHEQ.FO.010.3

Health Medical Form

Your answers to this questionnaire will be confidential to the company and will not be given to anyone without your written permission. The purpose of this form to to see whether you have any health problems that could place you at risk in the work- place. We may recommend adjustments or assistance as a result of this assessment.

Please provide 5 year employment history.

1.Please let us know if you are suffering from, or have suffered, from any of the following. Tick No, or Yes and detail additional information with supporting documents if required.

Eye problem, injury or disease(Required)
Do you need to wear glasses?(Required)
Allergies(Required)
Chest problems eg asthma, bronchitis etc(Required)
Diabetes(Required)
Infectious disease eg Hepatitis B, Tuberculosis(Required)
Peptic, gastric or duodenal ulcer(Required)
Indegestion(Required)
Epilepsy, fainting, black outs, giddiness or fits(Required)
Migraines or recurring headaches(Required)
Psychiatric/psychological disorders including anxiety, depression, eating dissorders, drug/alcohol dependence, self harm(Required)
Skin disease dermatitus, eczema(Required)
Abnormal blood presure or angina(Required)
Frequent sore throats, tonsilitus, colds or flu(Required)
Heart disease, chest pain, breathlessness or heart trouble(Required)
Muscle/joint problems arthritus, rheumatism, upper limb problems(Required)
Back or neck problems(Required)
Hernia (rupture)(Required)
Blood disorders(Required)
Kidney trouble or urinary infection(Required)
Injuries/deformaties of the limbs which may affect movement(Required)
Physical or mental impairment not detailed above that could be classed as a disability under the Equality Act 2010(Required)
Ringing/buzzing or any other noises in your ear(Required)
Are you or have you suffered any ear infections in the last 2 years?(Required)
Have you consulted your doctor about your ears/hearing?(Required)
Have you any noisy past times or hobbies?(Required)
Do you have any concerns about your ears/hearing?(Required)
Are you having, or waiting for treatment (including medication) or investigation at present?(Required)
Have you ever had any operations requiring hospital admission for five or more days?(Required)
Have you ever had to give up any previous job for medical reasons?(Required)
Have you been off work for more than a month in the last 5 years?(Required)
Do you think you need any adjustments or assistance to help do your job?(Required)
Have you been using hand-held vibrating tools/ machines in your job, or if this is a review since your last assessment?(Required)
If yes, tick any of the descriptions you have experienced
Have you ever had any other serious illness?(Required)
I declare(Required)
Clear Signature

Accreditations
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Accreditations
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