Crawshaw Hall
CONFIDENTIAL Medical centre & Nursing Home
HEALTH SCREENING
Name: / Date of Birth:PLEASE NOTE
A]. you should read this document carefully before attempting to answer any questions. All of the questions in this health declaration must be answered accurately and in full. You are advised that failure to disclose relevant health details about yourself could result in dismissal at a later date.
B]. When answering each of the questions, you should, where necessary provide details about any health problem/s you may have had in the past or currently have. Details should include the date of the onset of the illness / injury, the duration, the diagnosis (if known}, any medication or treatment received (from GP or hospital Consultant), the outcome [complete recovery, partial recovery, etc], any previous history or recurrence of the same problem, the frequency of episodes etc. In providing a detailed account regarding your health, it may not be necessary for you to undergo a health interview or medical check. Please be advised, if you fail to provide sufficient information, we will not be able to give an opinion to your future employer as to your fitness to undertake the duties of the post for which you have applied.
NO / DO YOU HAVE OR HAVE YOU EVER HAD, ANY OF THE FLOOWING / YES / NO / DETAILS OF PROBLEM
[Including dates, etc.]
01 / Asthma, hay fever or any other allergic condition, including sensitivity to antibiotic
02 / Eczema, dermatitis, psoriasis or other skin conditions [hands ever affected?].
03 / Chicken pox or shingles
04 / Herpes simplex [coldsores]?
05 / Frequent sore throats or sinusitis?
06 / A hospital acquired infection, such as multi Resistant Straph Aureus [MRSA]?
07 / A cough with blood stained sputum / spit?
08 / Bronchitis, pneumonia, pleurisy or recurrent chest infection?
09 / A cough for more than three weeks within the past year?
10 / Tuberculosis or close contact with someone who has had tuberculosis?
11 / An unexplained loss of weight, fever or night sweats during the past year?
12 / Heart disease, stroke, high or low blood pressure?
13 / Circulatory disorder, such as varicose veins, leg ulcers or Reynard’s phenomena?
14 / Chest pain or severe breathlessness upon exertion, e.g. when climbing stairs?
15 / Blood disorders, such as haemophilia, sickle cell or iron deficiency anaemia?
16 / Epilepsy, fainting attacks, fits of blackouts?
17 / Frequent severe headaches or migraine?
18 / Frequent ear infections or discharging ears?
19 / Any significant loss of hearing?
20 / Any eye conditions, injuries or defects of vision (including colour blindness)?
21 / Diabetes?
22 / Hernia, rupture or prolapse
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Print Name: ______
No / DO YOU HAVE OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING / YES / No / DETAILS OF PROBLEM(including dates, etc)
23 / Gastric or duodenal ulcers or frequent and prolonged attacks of indigestion?
24 / Dysentery, typhoid, gastro-enteritis, food poisoning?
25 / Bowel problems?
26 / Liver problems such as hepatitis or jaundice?
27 / Disorders of the bladder or kidney, including unitary tract infections?
28 / Spinal problems e.g. neck pain, back pain, disc problems or sciatica?
29 / Difficulty in bending, lifting or carrying?
30 / Any form of joint trouble, arthritis, hand or limb pains or stiffness?
31 / Any surgery / operations as a day – patient or a hospital in-patient?
32 / Depression, anxiety, phobias, mental illness or nervous breakdown?
33 / Any attempt at self harm
34 / Any eating disorder such as anorexia or bulimia or any unexplained weight loss or gain?
35 / Counselling, psychotherapy or psychiatric treatment?
36 / Any alcohol abuse or substance abuse?
37 / Any health problem or disorder that lowers your resistance to infections?
38 / Chronic fatigue syndrome or myalgic encephalomyelitis (ME)?
39 / Multiple sclerosis or other neurological disorders?
40 / Parkinson’s Disease?
41 / Any absences from work or school due to ill health or injury during the past two years (including number of days off and reasons)?
42 / Any conditions that required hospital treatment or investigation, please give name of hospital, the Consultant and your hospital reference number (if known)
43 / Are you at present receiving any treatment, injections, pills, tablets or medicines from your GP or other doctor?
44 / Do you smoke? If yes, how many per day? How many years have you smoke?
45 / Do you consider yourself to be disabled? If yes, please provide details of your disability. Identify any special needs or reasonable adjustments you may require to enable you to carry out all aspects of the roll detailed in the job description
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Print Name
No / DO YOU HAVE OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING? / YES / NO / DETAILS OF PROBLEM(including dates etc)
46 / Have you ever been medically discharged from any previous employment, HM Forces, or rejected on medical grounds for employment or insurance purposes?
Signature : ______Date ______
Print Name: ______
File/health screening/revised011205
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