Scribd
Upload
22 views

Health Declaration Form

The Health Declaration document requires employees to provide personal health information and answer a questionnaire regarding their medical history and current health status. This information is confidential and is used to ensure that employees are placed in roles that are safe for their health and to facilitate recovery in case of future illness. Employees must sign a declaration affirming the accuracy of their provided information.

Uploaded by

livyboo
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
22 views

Health Declaration Form

The Health Declaration document requires employees to provide personal health information and answer a questionnaire regarding their medical history and current health status. This information is confidential and is used to ensure that employees are placed in roles that are safe for their health and to facilitate recovery in case of future illness. Employees must sign a declaration affirming the accuracy of their provided information.

Uploaded by

livyboo
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
You are on page 1/ 3

Health Declaration

A: To be completed by the employee:

Name Address:

GP Name: Practice Address:

B: Please read the following carefully:


The following information is required with your interests in mind. Please complete the
questionnaire below as fully as possible. The information you provide will be treated as strictly
confidential. We ask for this information for two reasons:

 That any existing disease or disability does not necessarily preclude your appointment – but
knowing about it does assist the Company in being able to fit you into a job which is not in
any way harmful to your health;

 Even though you may be fit and well now, should you in the future become ill, we have the
background information to do as much as we can to facilitate your full recovery.

As a result of the information you have given you may be referred to a Doctor appointed by the
Company so that a medical examination can be carried out.

C: Have you ever:


Please answer the following questionnaire by circling either YES or NO. If you answer YES to
any of the questions, please give more details including your present state of health.

Please give further details

Had an operation or been seriously YES / NO


injured or received treatment for a
physical or mental condition which
might affect your capacity to do the
particular job for which you have
applied?

Been made ill by your work / suffered YES / NO


work related stress or upper limb
disorders such as RSI?
If you have been unavailable for work for medical reasons for one or more periods of more than
one week’s duration in the last three years, please provide details of the length of the absence
and the reasons for it:

How many days in total have you been absent from work due to ill-health (including minor
illnesses) in the past 12 months:

__________________________________________________________________________

D: Previous health problems/history


Have you ever in your life (including childhood) had any of the following, or do you currently
suffer from any of the following:

Please give further details

Diabetes YES / NO

Epilepsy/recurrent blackouts YES / NO

Heart Trouble, Angina, chest pains, YES / NO


rheumatic fever, etc

Asthma, Bronchitis or chest infections YES / NO

Skin problems, eg, Eczema, severe YES / NO


sensitive reactions

Bowel or gastric (stomach) disorders YES / NO


lasting for more than one week

High blood pressure YES / NO

Back associated illness YES / NO


Have defective eyesight/eyesight YES / NO
disorder

Suffered hearing defects (including ear YES / NO


pain, discharge, infection, etc)

Have you ever been treated for your YES / NO


nerves, depression, etc?

Are you or have you ever been YES / NO


registered disabled?

Are you currently on any hospital YES / NO


waiting list(s)?

Are you at present having any YES / NO


injections, pills or tablets prescribed by
your doctor?

E: Further information
Please detail any further information relating to your health which may require reasonable
adjustments, or will assist the Company in ensuring your safety whilst at work, e.g. allergies.

F: Declaration
I declare that to the best of my knowledge, all of the foregoing statements are correct. I
understand that if I am appointed and the information is incorrect, I may be liable for dismissal.

Signature:

Date:

You might also like