Medical Questionnaire

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Medical Questionnaire

Confidential — used only to assess fitness for work and any required adjustments.

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Full Name *

Email Address *

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Medical History

Please tick Yes or No for each condition.

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If you answered “Yes” to any of the above, please give dates and details

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Beliefs & Compliance

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Do any of your beliefs restrict you from working in any particular job or working environment? *
YesNo

If yes, please give details

Would you be prepared to take a drug or alcohol test? (Requirement of some customers) *
YesNo

Would you be prepared to participate in random searches at the client premises before/after or during your assignment? (Requirement of some customers) *
YesNo

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Adjustments & Food Hygiene (if applicable)

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Do you have any health-related conditions that will require reasonable adjustments to be made to the selection process? *
YesNo

If yes, please give details

Food handling: Please answer the following if you will be working with food.

At present, or in the last seven days, are you suffering from diarrhoea and/or vomiting? *
YesNo

If yes, give details

At present, or in the last seven days, are you suffering from stomach pain, nausea or fever? *
YesNo

If yes, give details

At present, are you suffering from skin infections of the hands, arms or face? *
YesNo

If yes, give details

e.g. boils, styes, septic fingers or discharge from eye / ear / gums / mouth? *
YesNo

If yes, give details

At present, are you suffering from jaundice? *
YesNo

If yes, give details

Do you suffer from recurring infections of the skin, ear or throat? *
YesNo

If yes, give details

Have you ever had typhoid or paratyphoid fever or are you now known to be a carrier of Salmonella Typhi or Para typhi? *
YesNo

If yes, give details

Are you a carrier of any type of Salmonella? *
YesNo

If yes, give details

In the last 21 days have you had contact with anyone, at home or abroad, who may have been a carrier of any type of Salmonella? *
YesNo

If yes, give details

Have you been overseas in the last 6 weeks? *
YesNo

If yes, give details of which countries

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Absence, Treatment & Exposure

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Please give details of any medical treatment you are currently receiving

Please give details of any medication you are taking

Have you had any serious illness or operation in the last 5 years? *
YesNo

If yes, please give details

Have you worked in an industry with high noise levels or been exposed to the use of hand held vibratory tools? *
YesNo

If yes, please give details and dates

Have you ever made a claim for Industrial Disease or injury? *
YesNo

If yes, please give details

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Declaration

I certify that I have answered the questions in this questionnaire honestly and fully and that I am not otherwise aware of any physical or mental disability which will or may affect my working capacity. I am aware that any false or incomplete statement may affect my appointment or future employment.

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Print Name *

Signature of Candidate *

Date *

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