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This questionnaire is designed to help assess your health and well-being in relation to your proposed employment. Please answer all the following questions. Your answers are confidential and used only in relation to your application as we aim to ensure that all employees are placed in a job which is compatible with their health and physical abilities. If you are unsure about completing any part of this form, please make a note of your concern in the relevant section. This questionnaire will only be viewed by a health professional. |
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SURNAME |
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FORENAMES |
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DATE OF BIRTH |
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NI NUMBER |
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HOME ADDRESS |
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POST CODE |
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TELEPHONE |
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SITE |
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JOB TITLE |
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1. |
Are you suffering from any illness or disability at the present time? If yes, please give details. |
Yes |
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No |
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2. |
Have you consulted a Doctor within the past two years about an illness or disability? If yes, please give details. |
Yes |
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No |
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2b. |
Did this lead to an absence from work? |
Yes |
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No |
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3. |
Have you had any other periods of sickness absence in the past two years? If yes, how many? |
Yes |
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No |
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4. |
Have you had any other serious illnesses or operations in the past? If yes, please give details. |
Yes |
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No |
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5. |
Are you taking or being given any medicines, inhalers, injections or eye/ear drops at the present time? If yes, please give details. |
Yes |
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No |
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6. |
Is your ability to perform physical work limited in any way? |
Yes |
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No |
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7. |
Are you restricted in your ability to work because of pain or stiffness in a joint or a limb? |
Yes |
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No |
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8. |
Have you ever had back pain sufficient to stop you doing your normal job? |
Yes |
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No |
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9. |
Do you get short of breath when walking on level ground for 100 yards or more? |
Yes |
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No |
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10. |
Does your skin ever get red, itchy, dry or sore? |
Yes |
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No |
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11. |
Is your hearing in any way abnormal? |
Yes |
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No |
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12. |
Do you have difficulty in reading because of poor eyesight? |
Yes |
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No |
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13. |
Can you read a car number plate at 25 yards/22 metres (as in the UK driving licence) with glasses if usually worn? |
Yes |
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No |
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14. |
Do you have any allergies? If yes, please give details. |
Yes |
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No |
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15. |
Have you had any previous accidents or illnesses due to work? If yes, please give details. |
Yes |
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No |
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16. |
Have you ever had to change job/shift because of your health? |
Yes |
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No |
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17. |
Have you received or claimed disability benefit? |
Yes |
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No |
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Declaration:
I certify that the answers to the above questions are correct to the best of my knowledge.
I understand that if I have withheld information, this may adversely affect efforts to place me in suitable employment. |
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Signature |
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Date |
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