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Prezzo South Woodford

HEALTH QUESTIONNAIRE
Name (please print):
Doctor’s Name and Address:

Have you, within the last three years, had any illness or accident causing you to be off work for two weeks or more? YES / NO
If YES, what was the illness or accident?

Have you, within the last three years, attended an outpatient’s clinic or had a course of treatment (tablets, injections,
physiotherapy) lasting one month or more? YES / NO
Are you now receiving such treatment? YES / NO
If YES, please give details.

Do you smoke? YES / NO


Are you suffering from, or have you ever suffered from –
Fits, epilepsy or blackouts? YES / NO
Diabetes? YES / NO
Depressive illness or nervous trouble (including eating disorders)? YES / NO
Diseases such as typhoid, cholera, hepatitis, recurring diarrhoea? YES / NO
Skin rash or dermatitis? YES / NO
Allergies (to drugs or to handling any substance)? YES / NO
Earache or ear infection? YES / NO
Back or sciatica? YES / NO
Have you ever been refused employment or dismissed on medical grounds? YES / NO
If YES, please explain.

I certify that the information on this form is correct and understand that any mis-statement or suppression of information will be
viewed as misconduct and will be subject to the Company’s Disciplinary Procedure.

Signature of Employee: Date: Sep 24, 2017

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