Health Check Questionnaire (Nursery Staff)

Doc. 1.1d

DOREMI NURSERY

Health Check Questionnaire (Nursery Staff)

Name: Position:
Address:
Please complete all sections of this declaration. It is essential that DoReMi Nursery are satisfied that you are medically fit to undertake the care of young children.
Section 1
Please give us the following details of your GP:
Name: Tel:
Address:
Section 2
Have you experienced any of the following medical conditions?
Medical Condition / Yes / No / Medical Condition / Yes / No
Back Injury / General Allergies
Epilepsy / Loss of sight, hearing or speech
Chest Pains / Dysentery
Heart Disease / Hernias
Recurrent Bronchitis / Rheumatism/Arthritis
Fits, giddiness or fainting / Chickenpox
High Blood Pressure / Skin Disease
Asthma / Mental health Problems/Nervous Breakdown
Tuberculosis / Permanent weakness of hand/limb
Diabetes / Serious disturbance of stomach/bowels
Migraines / Disease of kidney/bladder
Typhoid/Paratyphoid / Drug dependence
Stomach Ulcers / Alcohol dependence
Measles / Menstrual or gynaecological complaint
German measles / Obesity/anorexia
If you have answered ‘yes’ to any of the above, please state:
The nature of the condition:
The dates you were ill:
Please state if any of these conditions are ongoing
The treatment you received:
Section 3
Have you suffered or are currently suffering from any other illness(es)
not listed on the previous page which has resulted in permanent disability Yes No
or continuing medical treatment?
If ‘Yes’ please give details
Have you had any operation(s) or serious accident(s)/injury(ies) which
have resulted in permanent disability or continuing medical treatment? Yes No
If ‘Yes’ please give details
Are you, at present, under regular medical treatment/observation or
taking any regular medication under medical direction? Yes No
If ‘Yes’ please give details
Name and address of any specialist consulted during the last 2 years:
Declaration
I declare that I have carefully read all the questions and I have answered them correctly to the best of my knowledge. This form is a correct statement of my medical history.
I understand that DoReMi Nursery may wish to seek a report from my general Practitioner and give consent for this. I understand that this form could be copied to the doctor and shall have the validity of the original.
Signature of applicant ______Date ______