Health Assessment Questionnaire

Please read the following before reading the questionnaire and then complete all the
sections.
This questionnaire will be retained for the duration of your employment and to guide
the company on any special health requirements you may have during your
employment.

Detailed clinical information will not be revealed without prior written consent.
Should further information on any conditions be required from your General
Practitioner or Specialist this will be sought only after obtaining your written consent.

Failure to complete all sections fully may result in a delay in the confirmation of your
employment. Following assessment of this questionnaire you may be required to
undergo a medical examination.

In signing this questionnaire you confirm that all information provided is true to the
best of your knowledge. You also accept that on the event of being employed and it is
subsequently shown that relevant information has not been disclosed by you, or has
been misleading or false, then you could become liable to disciplinary proceedings
which may include dismissal.

If your application for employment is unsuccessful this questionnaire will be shredded.

For completion by the Applicant

Title : Mr, Mrs, Surname First name Date of birth

Ms,Miss

Home address and Telephone number Provider’s doctor /hospital and telephone no

For Completion by Employer

Job Title : Location : Start date :

Job Specification (please tick)

Overseas travel Fine color discrimination Working at heights

Regular car driver Predominantly walking Chemical exposure
Shift work Predominantly standing Regular lifting
Exposure to noise VDU work Driving Heavy equipments
(i.e fork lift, dump truck,
transportation truck)
 For completion by the Applicant :

1.1. Are you currently in good health? (YES/NO)

If NO give details:
……………………………………………………………………………………………………………
1.2. Have you previously or are you currently suffering from any substantial disability?
(YES/NO)
If YES give details: …………………………………………………………………………………………………………
1.3. Have you been absent from work or college due to sickness for more than two weeks in
the last 12 months? (YES/NO)
If YES give details:
…………………………………………………………………………………………………………………
1.4. Are you currently undergoing investigations or treatment? (YES/NO)
If YES give details:
…………………………………………………………………………………………………………………
1.5. Have you ever claimed Industrial Injury or Incapacity Benefits? (YES/NO)
If YES give details:
………………………………………………………………………………………………………
1.6. Have you been refused employment or taken early retirement on health
grounds? (YES/NO)
If YES give details:
…………………………………………………………………………………………………………

1.7. Occupational History:

Dates Employer Place Job title and nature of work

1.8. Family History:

Is there any family history of diabetes, heart disease, stroke, high blood pressure,
nervous disorder?
or any other hereditary disorders? (YES/NO)
If YES give details:
..........…………………………………………………………………………………………………………………………

1.9. Others :

1. Have you ever smoked? (YES/NO)

Are you a current smoker? (YES/NO)
If so, please indicate number per day: ................ cigarettes
2. Do you drink alcohol? (YES/NO)
If YES, state how many glass per week …………………
3. Do you exercise regularly? (YES/NO)
If YES, do you exercise for more than twenty minutes three times a week?
4. Please list any medication you take on a regular basis:

1.10. Health History:

Please circle one if you have had investigation, advice or treatment for the following,
and if so give details on the last page

a. 1. Stress, or sleep disorder b. 1. High blood pressure

2. Anxiety/depressive illness
3. Other nervous disorders
4. Attended for counseling
surgery
c. 1. Recurrent indigestion
2. Peptic ulcer
3. Hepatitis/liver disease
4. Hernia
e. 1. Significant menstrual disorders
2. Abnormal cervical smears
3. Breast disorders
g. 1. Blood disorders e.g. anaemia
2. Allergies, including hay fever
3. Chronic fatigue syndrome
4. Cancer or other malignant
disease
i. 1. Impaired hearing
2. Other ear conditions
2. Heart disease
3. Angina or other chest pain
4.Coronary by-pass or other heart
d. 1. Cystitis/urinary tract infection
2. Kidney stones
3. Other kidney diseases/transplant
4. Prostate or testicular disorder
f. 1. Diabetes mellitus
2. Thyroid disorders
3. Other Endocrine disorders
h. 1. Impaired sight
2. Impaired colour vision
3. Glaucoma/other eye conditions
j. 1. Contact dermatitis
2. Psoriasis/other skin conditions

k. 1. Recurrent headaches/migraine l. 1. History of tuberculosis

2. Blackouts or fainting fits 2. Persistent cough or sputum
3. Epilepsy 3. Shortness of breath with
4. Vertigo/Tinnitus exercise
5. Head injury or serious accident 4. Asthma

Please list any surgery or/and any hospitalization you have had

If you have any other health problems you would like to discuss with the physician,
please list them here:
……………………………………………………………………………………………………………………………………………
………………..…………………………………………………………………………………………………………………………
…………………………………..…………………………...................................
DECLARATION:
1. I declare all the above answers to be true and correct to the best of my
knowledge.
2. I understand that withholding information or giving false answers may lead to
dismissal.
3. I agree to follow all the medical test as required by the Company (choose yes
or / no)

YES NO

If I become the employee of the

Company, during my employment
period any consequences arise from
my fully and/or partially rejection of
the medical test will solely become
my responsibility.

Candidate’s signature: Date:

Doctor’s Comments: Date: