PRE-EMPLOYMENT HEALTH HISTORY QUESTIONNAIRE
For completion by applicant (using black ink):
Dear Applicant
The purpose of this form is to ensure that you will be able to carry out the duties required of you without risk to yourself or others.
Your answers will be treated as confidential. Please read the questions carefully and complete them as accurately and as fully as possible. Once completed, please return this questionnaire with your application form to Mrs Lynne De Gruchy, Business Manager, at the school by the closing date.
Full Name: Dr/Mr/Mrs/Ms/Miss......
Date of Birth ……………………… National Insurance Number …………………………………….
Home Address …………………………………………………………………………………………….
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County ……………………….…………………… Post Code ………………………………………….
Home Telephone Number ……………………….. Daytime Contact Number …………………………
Email Address …......
For completion by Personnel Department:
Job Title …………………………………………………………………………………………………..
Location ..HOLY TRINITY C E PRIMARY SCHOOL, TRINITY ROAD, GRAVESEND, KENT, DA12 1LU
Personnel Officer Contact ..MRS LYNNE DE GRUCHY – BUSINESS MANAGER
Personnel Contact Telephone Number ..01474 534746
Work Related Health History
a. Have you ever been absent from work or full time study due to ill health during the last 2 years for any period longer than 7 consecutive days ?
YES/NO Please circle. If yes, please give dates and details
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b. Have you ever left, or been denied a job on health grounds ?
YES/NO Please circle. If yes, please give dates and details
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c. Have you ever suffered from any work-related health conditions?
YES/NO Please circle. If yes, please give dates and details
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Health History
Do you have or have you had in the past :-
a. Lung problems/conditions of the lungs ?
YES/NO Please circle. If yes, please give details
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b. Heart problems/conditions of the heart ?
YES/NO Please circle. If yes, please give details
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c. Nervous system problems/conditions of the nervous system ?
YES/NO Please circle. If yes, please give details
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d. Migraine or persistent headaches for which you take medication ? Please state
YES/NO Please circle. If yes, please give details
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e. Digestive system problems/conditions of the digestive system ?
YES/NO Please circle. If yes, please give details
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f. Kidney or bladder problems/conditions of the kidneys or bladder?
YES/NO Please circle. If yes, please give details
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g. Bone, joint or limb problems/conditions of the bones, joint or limbs ?
YES/NO Please circle. If yes, please give details
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h. Allergies ?
YES/NO Please circle. If yes, please give details
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i. Skin conditions ?
YES/NO Please circle. If yes, please give details
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j. Endocrine conditions ?
YES/NO Please circle. If yes, please give details
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k. Alcohol or drug problems ? Problems related to alcohol or drug usage or dependency ?
YES/NO Please circle. If yes, please give details
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l. Mental or psychological health problems ?
YES/NO Please circle. If yes, please give details
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m. Have you consulted a specialist or needed any operations other than already stated ?
YES/NO Please circle. If yes, please give details
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n. Have you spent any time in hospital other than already stated ?
YES/NO Please circle. If yes, please give dates and details
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o. Have you consulted your GP in the last 12 months ?
YES/NO Please circle. If yes, please give details
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p. Are you currently waiting for or receiving treatment from your doctor or any other health professional or therapist ?
YES/NO Please circle. If yes, please give details
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q. Do you take any doctor prescribed medication ?
YES/NO Please circle. If yes, please give details
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r. Do you have any restrictions with the use of any of your limbs ?
YES/NO Please circle. If yes, please give details
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s. Do you have any problems with your eyesight ?
YES/NO Please circle. If yes, please give details
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t. Do you have any problems with your hearing ?
YES/NO Please circle. If yes, please give details
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u. Do you consider yourself to have a disability ?
YES/NO Please circle. If yes, please give details
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v. Have you any other health issues that have not been mentioned above or about which you would like to provide further details?
YES/NO Please circle. If yes, please give details
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Declaration
- 1 declare that the answers contained in this Health Questionnaire are true to the best of my knowledge
- I will attend for further health interview/examination if this is required
- I agree to information being given to the employer with regard to my fitness for work including any recommendations or adjustments that may need to be put in place
Signature of candidate …………………………………………… Date ……………………………….
For Office Use only:
FIT …
FIT WITH ACCOMMODATION/RECOMMENDATIONS …
DEFERRED PENDING FURTHER INFORMATION …
DEFERRED PENDING HEALTH SERVEILLANCE ASSESSMENT …
INCOMPLETE FORM, TO BE RETURNED TO EMPLOYEE …
Pre-Employment Health Questionnaire – Lynne De Gruchy – Business Manager