Pre-placement Health Declaration / YOUR LOGO HERE

This declaration form is used to assess your medical fitness to work. In addition to completing this form, you may be asked to attend an Occupational Health assessment with a nurse or a doctor. Reasonable adjustments will be made in accordance with the Disability Discrimination Act. Your prospective employer will be informed of the results of the assessment and of any recommendations for adjustments that you may require. The information you provide will be treated sensitively and stored in accordance with the Data Protection Act.

Please:

answer all questions fully and honestly: failure to do so may delay your appointment or result in the termination of your employment.

do not refer to another document held by the person responsible for your recruitment: this may delay your appointment

do not include any other information required by the person responsible for your recruitment in the sealed envelope with this document as this declaration form is forwarded directly to Occupational Health

When you have completed this declaration form, please return it, sealed, in the envelope provided.

Should you require assistance in completing this form, please contact Occupational Health on 01484722444: we will arrange for an Occupational Health Advisor to contact you.

Surname: / Forename:
Previous Names: / Date of Birth:
Address:
Postcode:
Telephone Day: / Evening:
GP Name and Address:
Position applied for:
Hours per week / Due Start Date:
Pattern of work (e.g. days / nights / rotational shifts days only / rotational shifts including nights
For Occupational Health use only:
Fit / Yes / No / Date: / Sig: / Received / Date:
GP Letter / No / Yes / Date: / Sig: / Notified / Date:
OHA appt / No / Yes / Date: / Sig: / Ref HSurv / Date:
OP appt / No / Yes / Date: / Sig: / Preg Letter / Date:
Restrictions / No / Yes / Date: / Sig: / HAVS / LW / MSD / RM
Restrictions R/V / No / Yes / Date: / Sig: / Skins / NW / Drivers / Audio

Do you have, or have you ever had any of the following? – if the answer to any of the question is YES, please give details including dates.

Description
(including but not limited to) / No / Yes / Details including dates
Skin problems
(eczema, dermatitis, or scaling, weeping or discharging lesions)
Gastro-intestinal problems
(diarrhoea, vomiting, Crohns, Irritable Bowel Syndrome, Diverticulitis)
Gastro-intestinal infection
(food-borne disease, food poisoning, enteric fever, dysentery, giardiasis, E coli hepatitis A, typhoid and paratyphoid infections,)
Respiratory problems
(asthma, tuberculosis, bronchitis, recurring or persistent cough)
Back or neck problems
(sciatica, aches, pains or injuries, deformities)
Impairment or disability of the upper or lower limbs(limited movement/strength, altered sensation, pain, including hand-arm vibration syndrome)
Vision problems
(eye infections, uncorrected defects)
Ear problems
(recurring infections, difficulty hearing)
Neurological problems
(epilepsy, seizures, dizziness, blackouts, loss of consciousness, repeated lapses of memory/concentration, persistent or recurrent headaches/migraines, balance disorders)
Diabetes
(diet, oral tablet or insulin dependent)
Heart or circulatory problems
(high or low blood pressure, angina, peripheral vascular disease)
Psychological problems
(anxiety, depression, stress, episodes of disorientation, agitation, episodes of self-harm, violence, aggression)
Communication problems
(speech difficulties, difficulties with written word)
Mouth or throat problems
(weeping or pustular lesions of mouth / gums, recurring throat problems)
Sensitivities or allergies
(food, medicines, latex, dust)
Are you currently pregnant, breastfeeding or have given birth in the last 6 months?
Are you currently taking any prescribed or over the counter medications?
Have you ever had any health problems related to your work?
Do you drink alcohol? / amount per week
Have you ever taken any substances for recreational purposes?
Have you ever claimed a disability pension, industrial injury benefit, been refused life insurance or employment on the grounds of ill health? No / Yes – please give details
Are you currently receiving, or awaiting treatment for a physical or mental health problem?
No / Yes – please give details
Date from - to / Reason /
Treatment
Have you ever consulted a health care professional within the last two years (eg. GP, specialist, counsellor, complementary therapist, physiotherapist)? No / Yes – please give details
Date from - to / Reason /
Treatment
How many days sick leave have you had during the past two years? None / please give details
Date from - to / Number of days /
Reason for absence
Please list your previous occupation(s) and employer(s) or schools attended (Continue on a separate sheet if necessary)
From / To / Employer or School / Occupation / Known Occupational Hazards
What is your height?: / Weight?:
What is your weekly consumption of alcohol?:
What are your hobbies or pastimes?:
I certify that the information given by me for the purpose of assessing fitness to work is true, to the best of my knowledge and belief, and that I have not withheld any material facts. I understand that, in the event of my knowingly making a false statement or concealing pertinent information, the Occupational Health Service may disclose to Arla Foods management that a false statement has been made, without releasing medical details of that false statement without my further consent. I understand that Arla Foods may treat this false statement as gross misconduct and terminate my contract.
Signed:
Print name: / Date:

Please check:

  • that you have completed all the sections in the declaration form. Failure to complete all sections may result in the form being returned to you and a delay in your appointment.
  • That you have not referred to another document held by your prospective employer, as Peritus Health Management does not have direct access to any documents help by your prospective employer and this may delay your appointment.
  • That you have not included any other information required by your prospective employer within the sealed envelope, as this declaration form is forwarded unopened to Peritus Health Management.

Peritus Health Management

1 High Street – Brighouse – HD6 1DE

Tel / Fax 01484 722444

Company No: 5491540

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