Job Position applied for / Reference No
First Name *
Surname *
DOB *
Address *
Postcode *
Email *
Home Tel
Mobile
How many days have you been absent from work due to sickness during the past 12 months?
Over how many different occasions?
What was the reason for each absence on each occasion?
Please give any further details
Do you suffer from any of the following? Please tick, if appropriate and give details
Please hold down the Cmd Key
Medical Condition Medical Condition Arthritis Asthma Asthma Blood disorder Diabetes Eating or Mental Disorder Eczema Epilepsy Fainting Hearing difficulty Heart Condition High Blood Pressure Infection of Kidneys Lung disorder Migraine Sight impairment Slipped disc or other back injury Stomach complaint
If Selected Any, please give further details for each condition
Do you suffer from any other medical condition?. If Yes, please give details
Are you receiving medical attention for any complaint? If Yes, please give details
Have you suffered any injury in the past three years? If Yes, please give details
Do you consider yourself to be disabled? If Yes, please give details including any adjustments that you might require to the job or workplace.
Do you consider yourself to be in good health? If No, please give details.
General Practitioner’s information
Would you be prepared to allow us to seek further information about your health from your GP or other doctor providing care for you, in accordance with the Access to Medical Records Act 1988?
Yes I Agree, please contact them
Name & Address of Doctor / Surgery
I hereby confirm that the information I have provided in this questionnaire is, to the best of my knowledge, accurate and true. I understand that giving any false or misleading information could lead to dismissal. *
