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Employment Medical Form

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agrawalkunal1807
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18 views

Employment Medical Form

Uploaded by

agrawalkunal1807
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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EMPLOYMENT MEDICAL

QUESTIONNAIRE

APPLICANT'S JOB DETAILS

To be completed by ALL applicants:


Name: Kunal Agrawal Position applied for: Manager-Compliance &
Legal

Designation: Manager- Compliance & Legal Department: Finance & Legal


Name of person Fitness for Work report to be sent Place: Faridabad
to:

APPLICANT'S PERSONAL DEATAILS

Address: House no : 834 Sector- 31 Faridabad, Telephone numbers: Home:


Haryana-121003 9711605094

Work: 9911173221

Postcode: 121003

Date of Birth (dd/mm/yy) :14/09/ 1990 / Age (Years): 32 Sex : M F

Personal Mobile Phone and Home Email information

Do you consent to being contacted by email? Yes Home email address:


No If Yes,
please provide your home email address
Do you consent to being contacted on your mobile? Yes Mobile phone number:
N 9911173221
o If Yes, please provide your mobile phone number

PART 1:

Please answer all of the following questions by ticking the box Yes No
1 Are you on a hospital waiting list for investigation or treatment?
2 Are you regularly attending a hospital, community clinic or seeing a doctor?

Have you ever left a previous employment through ill health or work related injury or
3
condition
Are you suffering from or have you ever suffered from: Yes No
4 Any conditions relating to your heart or circulation?
5 Any respiratory problems? (e.g Asthma)
6 Any psychological problems? (e.g nervous breakdown/depression)
Any eyesight condition that cannot be corrected by wearing spectacles or contact lenses?
7

8 Any ongoing hearing problems or ear disorders? (e.g Tinnitus)


9 Any ongoing bone, muscle or joint problems? (e.g Recurrent back
pain/Arthritis)
10 Any skin diseases or conditions that require medical treatment?
11 Any gastro-intestinal or abdominal problems? (e.g Hernia/Gall Stones)
12 Any blood or metabolic disorders? (e.g Anaemia/Diabetes)
13 Any neurological conditions? (e.g severe headaches/vertigo/epilepsy)
14 Any long term or debilitating illness? (e.g Multiple Sclerosis)

Vaccinations (please give dates of last vaccination)

Hepatitis A / / Tuberculosis (BCG) / /


Hepatitis B / / Tetanus / /
Initial injection / / Polio / /
nd
2 injection / / Rubella (Measles) / /
st
rd
3 injection / / Covishield 1 dose 02/09 /2021
5 yr booster / / Covishield 2nd dose 29/11 /2021

EQUALITY ACT 2010 It is unlawful to discriminate against disabled people in connection with employment. A person
is considered disabled if they have a physical or mental impairment which has a substantial and long term adverse
effect on their ability to carry out normal day-to-day activities. In order to comply with the Equality Act your
prospective employer needs to know if you have a physical or mental impairment which may be considered a disability
within the Act
The details of your disability cannot be provided to your prospective employer without your written consent. It may
be helpful for them to understand the nature of your disability in order to consider what adjustments may need to be
made to the workplace to help you perform your job effectively and to comply with Health and Safety.

Disability Yes No
Do you have any kind of chronic health condition or disablement?
(If yes, please answer both questions below)
Do you believe that this condition or disablement might bring you within provisions
of the Equality Act 2010?

Declaration of Fitness:

I certify that I have answered all questions in Part 1 of this form to the best of my ability and knowledge, and am able to
answer NO to ALL questions. I have no reason to believe that my health will interfere with my ability to undertake the
duties of the post for which I have applied, or affect my ability to give good attendance. I understand that withholding
information, or knowingly giving incorrect information, about my health on this form may result in disciplinary action
or dismissal.

Signed: Date (dd/mm/yy): 29/09/2022

I certify that I have answered all questions in Part 1 of this form to the best of my ability and knowledge and am able to
answer YES to some of the questions. I have no reason to believe that my health will interfere with my ability to
undertake the duties of the post for which I have applied, or affect my ability to give good attendance. I understand that
withholding information, or knowingly giving incorrect information, about my health on this form may result in
disciplinary action or dismissal.

Signed: Date (dd/mm/yy): 29/09/2022

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