Medical Questionnaire

As part of Towergate’s pre-employment fitness screening we ask you to complete the following questionnaire so that any health or medical issues can be addressed. This information is strictly confidential and will only be seen by HR and/or its appointed medical advisor in the case of any referral.

If you have a medical condition such as diabetes or epilepsy you are encouraged to share this information with your line manager and the first aider in your office in case of emergencies.

Full Name / Title / Date of Birth
Doctors Name and Address / How many days absencehave you had due to sickness or injury in the last 12 months? (do not include sickness due to pregnancy)

Please answer the following questions carefully by ticking the appropriate box.

Yes / No /

If NO please give full details

Are you in good health?
Is your hearing good?
Is your eyesight good?
Yes / No /

If YES please give full details

Do you consult an optician?
Do you have a speech disorder?
Have you any disability that could be classed as a disability under the Equality Act 2010
under the ?
Have you at anytime suffered from any of the following: / Yes / No / Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.
Headaches/migraines/blackouts/epilepsy/mental or nervous disorders/anxiety or depression?
Have you ever seen a psychiatrist or had an emotional or psychological disorder?
Have you at anytime suffered from any of the following: / Yes / No / Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.
Tuberculosis/asthma/pneumonia/
Bronchitis/pleurisy/persistent cough/or any other disease of the lungs?
Any heart trouble/high blood pressure/palpitations/fainting/rheumatic fever?
Diabetes/kidney disease/bladder or urinary trouble?
Rheumatism/arthritis?
Back trouble/lumbago/sciatica?
Haemophilia or any blood disorders?
Any other condition needing hospital attendance, serious injury, operation or sickness absence for more than one month.
Are you awaiting hospital admission for tests or any other reason?
Are you currently receiving medical treatment, under observation or undergoing medical tests?
Are you currently taking any pills or medication for any other reason?
Have you ever had any difficulty in using VDU or other keyboard/screen based equipment, and if so, has this resulted in problems for which you have needed medical advice or treatment?
Have you ever-left employment on the grounds of ill health?

Please check that you have answered all the questions above before reading and signing the declaration below.

Employee Declaration

I declare that to the best of my knowledge and belief that the particulars given are true and correct and that I have not withheld any information or material fact. (Please note that any deliberate attempt at concealment of material evidence may potentially be grounds for dismissal at a later date).

I confirm that by signing this form I have agreed to consent to referral to a medically qualified person should Towergate deem it necessary, and give my permission for any medical or sickness record to be held, in confidence, by Towergate.

Signed:………………………………………………………..

Print Name:………………………………………………………..

Date:………………………………………………………..

If the company requires you to undergo a medical examination or provide authority for medical reports to be sought from doctors who have attended you, you will be advised separately.

Data Protection

For the purposes of compliance with the Data Protection Act 1998, I hereby give my consent to Towergate processing the data supplied in this questionnaire for the purposes of recruitment and selection.

1

January 2011