KNOWLE WEST HEALTHASSOCIATION
RECRUITMENTPOLICY – APPENDIX 2
HEALTH QUESTIONNAIRE
The purpose of this document is to assess your health so that we can comply with our Health and Safety obligations. By assessing your health we can make sure we do not ask you to perform tasks which may adversely affect your health.
We are an Equal Opportunities employer and we do not discriminate against applicants on the grounds of disability, race, age, sex or sexual orientation, religion or beliefs or marital status. Any information contained in this form will be considered in accordance with our policies against discrimination and our legal obligations.
The information you provide is confidential and will not be shared without your written agreement. Your GP will not be contacted without your written consent.
Failure to answer questions in this form truthfully or the giving of false information will be considered gross misconduct and may result in disciplinary action in the event that it is discovered after you have been appointed and may lead to your dismissal.
Section 1 - About you
Name: …………………………………………………………………………….
Home address: …………………………………………………………………..
……………………………………………………………………………………..
……………………………………………………………………………………..
Home telephone number: ………………………………………………………
Date of birth: ……………………………………………………………………..
Height: …………………………… Weight: ……………………………………
GP’ name: ………………………………………………………………………..
GP’s address: ……………………………………………………………………
……………………………………………………………………………………..
……………………………………………………………………………………..
GP’s telephone number: ………………………………………………………..
Section 2 – medical history
Please tick the Yes or No column if you currently have, or have had in the past, any of the following medical conditions or illnesses: / Yes / No1. Infectious diseases.
2. Heart disorders or any disorders of the circulatory system such as hypertension or angina.
3. Kidney or bladder problems.
4. Chest or respiratory problems such as tuberculosis, bronchitis or asthma.
5. Eye or visual problems/conditions/diseases not corrected by prescribed glasses/lenses, such as glaucoma, blurred or restricted vision.
6. Hearing or ear-related problems.
7. Speech disorders.
8. Known allergies, which can include hayfever or allergic reactions.
9. Recurring infections of the nose mouth and throat.
10. Skin problems such as eczema, psoriasis and sensitivity to any chemicals including detergents.
11. Back, neck or joint problems such as arthritis and sciatica, or a “slipped disc”.
12. Shoulder, elbow, hand or finger problems including repetitive strain injuries.
13. Headaches or migraines.
14. Epilepsy, fainting or blackouts.
15. Stomach or bowel problems such as duodenal or gastric ulcers or hernias.
16. Diabetes.
17. Psychiatric problems or mental illnesses, which can include stress and anxiety, depression or eating disorders.
18. Any other known medical condition which may affect your performance or attendance at work.
19. Are you pregnant?
20. Has your driving licence ever been withheld on medical grounds by the DVLA?
21. Have you been treated for drugs or alcohol problems?
22. Are you currently undergoing medical treatment or investigation or are you on a hospital waiting list?
23. Do you take any regular medication, and what for?
24. Do you have any disease or injury which has been caused by work?
25. Do you have a disability (as defined by the Disability Discrimination Act 1995)?
26. Have you during the past five years been unable to work through illness for a period of more than three weeks?
Section 3 – further details
If you have answered yes to any of the questions in the previous section please provide further relevant details here. If your health or ability to work is affected by an illness or medical condition not covered in the previous section please give details:
Section 4 – declaration
I have answered the questions truthfully and to the best of my knowledge. I understand that failure to disclose any relevant information may lead to disciplinary action or dismissal. I understand that I may be asked for further medical information or for my consent to my GP being contacted, or to attend a medical examination.
Signed: ………………………………………………………………………………
Dated: …………………………………….
Consent under the Data Protection Act 1998: The information given in this form will be processed only by Knowle West Health Association for the purpose of considering your application for employment. If you are successful in your application this form and the information in it will be retained in your Personnel file for such time as you are an employee and for up to 6 years after the end of your employment. Otherwise this form will only be retained by us for so long as it is required in connection with your application. By signing this consent you give us your express consent to retain and process all the information
Signed for and on behalf of the Dated
Knowle West Health Association
IG010809
Registered in England and Wales as Knowle West Health Association
Company No. 4164235, Charity Registration No.1104429
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