Pre-commencement Health Assessment

The Pre- commencement Health Assessment must be completed by the applicant and returned to the address quoted in the box below.

The pre-commencement health questionnaire is managed by Prevent plc, an independent organisation whowill retain the questionnaire and your answers. It will be used to assess whether there are any health issues relevant to the proposed work and to guide Options Group on any special requirements you may have during employment. Further assessment by Options Group may be needed and you may be required to attend for regular health surveillance during employment.

Advice regarding fitness for work will be given to your employing officer in general terms; detailed clinical information will not be revealed without your consent.

If further information is required from your GP or Specialist this will only be obtained with your written consent.

In agreeing to this questionnaire you confirm that all information provided is true to the best of your knowledge. You also accept that if it is subsequently shown that medical information has not been disclosed by you, or has been misleading or false, then you could become liable to disciplinary proceedings that may include dismissal.

Prevent plc are employed by Options Group to manage the Pre-commencement Health Assessment. Prevent plc is governed by the Data Protection Act 1998 and none of your personal information will be given to a third party outside of Prevent plc or your employer unless legally obliged to do so.

A representative of Prevent plc may call you on the contact numbers you have provided within the Personal Details section, to ask you some additional Health Assessment questions.

The information provided by you will be recorded and will form part of this Health Assessment. The assessment results may be used in the future should for any reason you be absent from your employment.

*I permit Options Group to input my

data into the Prevent plc system on my behalf.

I confirm that I agree to the terms above

Simply tick one of the following;

Yes:  No: 

Signed by the participant:

Dated:

Prevent plc : PO Box 514, Weybridge, Surrey KT13 8QL :
Pre-commencement Health Assessment
Please complete the following questionnaire, answering every question
Personal Details
Title / First Name / Surname
Date of Birth / Home Tel
Work Tel / Mobile Tel
Home Address
Email Address
Health Questions
1. How many jobs have you had in the last 5 years?
2. How many days have you been absent from work or full time study due to ill health during the last 12 months (including illness such as colds etc)?
3. Have you ever left, or been denied a job on health grounds? / Yes / No
4. Have you ever been denied an insurance policy on health grounds? / Yes / No
5. Have you ever been advised to notify the Vehicle Licensing Centre of a medical condition? / Yes / No
6. Have you ever had to stop work for more than one month for a medical reason? / Yes / No
7. Have you ever been retired early on grounds of ill health? / Yes / No
8. Have you ever had any of the following diseases/injuries caused by a previous job?
Repetitive Strain Injury (RSI) / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Depression or other psychological illness / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Asthma / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Deafness / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Eye problems / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Dermatitis/Psoriasis/Other / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Back pain / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Vibration White Finger/Hand Arm Vibration Syndrome / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Neck pain / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Joint problem / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
Other injuries/work related illnesses / Yes / No
If yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required:
9. Have you had to work in any jobs that exposed you to the following hazards?
Heavy physical work / Yes / No
Chemicals / Yes / No
Vocational driving / Yes / No
Biological agents / Yes / No
Repetitive upper limb movements / Yes / No
Machinery operation / Yes / No
Extremes of temperature / Yes / No
Travel / Yes / No
Noisy work environment / Yes / No
Dusty environment / Yes / No
High pressured, demanding job / Yes / No
Working at height / Yes / No
Working with machinery that vibrates the hands, arms or body / Yes / No
Display screen equipment use / Yes / No
Working alone in isolation / Yes / No
Powdered latex gloves / Yes / No
Confined spaces / Yes / No
Night work / Yes / No
10. Do you have a condition of the heart (High blood pressure, Heart attacks, Angina or any other condition)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
11. Do you have a nervous system disorder (Blackouts, Epilepsy, Muscular weakness, Paralysis or any other condition)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
12. Do you suffer from Migraines or persistent headaches? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
13. Do you have a condition of the digestive system (Irritable bowel syndrome, liver complaints, jaundice, colitis, gastric, duodenal ulcer or any other condition)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
14. Do you have a condition of the kidney or bladder (Urinary infection, kidney stones)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
15. Do you have a condition of the bones, joints and limbs (Arthritis, rheumatism, back problems, neck or shoulder problems, sciatica, upper limb disorder, tennis elbow or any other conditions)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
16. Do you suffer from an Allergy (Including allergies to drugs, animals and pollens)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
17. Do you have a Skin condition (Eczema, dermatitis, psoriasis, recent infection, skin cancer or any other condition)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
18. Do you suffer from Gland trouble (Diabetes, Thyroid, any other condition)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
19. Do you have any Eye conditions (Restricted vision, Glaucoma or any other condition? You do NOT need to include short or long sight issues which are corrected by wearing glasses)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
20. Do you have any Ear conditions (Restricted hearing, Tinnitus, Ear infections or any other condition)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
21. Do you have Alcohol or drug problems (problems related to alcohol or drug usage or dependency)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
22. Do you suffer or have you suffered from Mental illness and/or stress related problems (Nervous breakdown, mental fatigue, anxiety, depression, panic attacks, significant sleep disturbance, stress related problems, eating disorders, self harm or any other conditions)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
23. Have you consulted a specialist or needed any operations other than already stated? / Yes / No
If yes, explain issue?
24. Have you spent any time in hospital other than already stated? / Yes / No
If yes, explain issue?
25. Have you consulted your GP in the last 12 months (other than to discuss or review contraception)? / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
26. Are you receiving medical treatment at the present time? / Yes / No
If yes, explain issue and what treatment?
27. Do you take any regular medication? Other than contraception / Yes / No
If yes, what medication?
28. Are you aware of having any disability that is covered by the Equality Act?* (Disability Discrimination)
If you would prefer not to disclose what the Equality Act issue relates to within this questionnaire to your employer, please use this section to request a telephone call and a member of our team will contact you to discuss.” / Yes / No
If yes, explain issue
29. Have you any other health issues that have not been mentioned above? E.G Dyslexia or Dyspraxia / Yes / No
If Yes, please describe the issue, when it happened, is it still a problem and whether medication or ongoing action is required
30. When did you last have an eye check?
31. If your job will require you passing a Physical Intervention Course – do you know of any reason why you might not pass? / Yes / No
Please use the space below and overleaf to expand on any issues you may have raised by answering the above questions;