Pre-employment medical questionnaire form template
This questionnaire collects specific job-related information about a post, and relevant health information about the new starter.
- 3 pages / 929 words
- Instantly download as Word / PDF / plain text
- Suitable for worldwide use (but check local legislation)
- Includes 12 months’ access, with all updates to this page provided free of charge and notified to you.
Pre-employment medical questionnaire form
[Employees starting jobs that involve work with hazards (e.g. sensitising chemicals, allergens etc) or safety-critical activities (e.g. night work, driving a vehicle etc) must complete and return this medical questionnaire before commencing employment.]
An answer must be provided for all questions. The information will be treated in confidence by the Occupation Health Adviser.
PLEASE COMPLETE IN CAPITAL LETTERS
| Position applied for: |
Personal details
| Title: | Mr | Mrs | Ms | Mx | Dr | Other |
| Full Name: | |
| Address: | |
| Contact telephone: | |
| Date of birth: |
GP details
| GP name: | |
| Address: | |
| Telephone: |
Occupational hazard history
| Please note the job titles, dates, and nature of any known hazards to which you have been exposed. |
Medical history
Please complete the following questions by ticking the appropriate box. If the answer is yes, give details including (a) date, (b) amount of time lost from work/school, (c) treatment, as appropriate.
| Visual defects/eye conditions (including colour-blindness): | Yes | No |
| Hearing defects/ear conditions: | Yes | No |
| Severe anxiety, depression, other psychiatric disorder: | Yes | No |
| Paralysis or other neurological disorder: | Yes | No |
| Fainting attacks, blackouts, epilepsy or fits: | Yes | No |
| Recurrent headaches, migraine: | Yes | No |
| Vertigo, giddiness or tinnitus: | Yes |
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This information can be assessed by OHS advisers or other qualified personnel, who can:
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Assess the candidate's medical capability to do the job for which they have applied: this will include assessing whether there are any statutory and legal reasons why an individual may not carry out particular work: for example, health and safety regulations would mean that a candidate with epilepsy would not be allowed to undertake a post involving driving; and
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Provide advice to departments to ensure that none of the role's duties will adversely affect any pre-existing health conditions the candidate has declared.
Frequently Asked Questions
Frequently Asked Questions
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Can I use this template in my small business?
Yes. The Pre-employment medical questionnaire form template is designed to be flexible and suitable for organisations of all sizes, including small businesses and charities. It follows UK employment law best practice, so even if you don't have an in-house HR team, you can confidently apply it.
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Is this template compliant with 2025 UK employment law?
Absolutely. All of our templates are drafted with the latest ACAS guidance and UK employment legislation in mind. We review and update them regularly, so you can be confident they remain compliant.
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Can I customise it for my organisation?
Yes, we highlight the areas that you need to update with your own details, and where you need to make decisions to suit your situation. This saves you time and ensures that you meet best practice.
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Do I get instant access?
Yes. Once purchased, you'll be able to download it instantly. Templates are provided in editable Word or Excel format so you can customise them easily, and in PDF format for easy sharing.
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What if I need more help, not just this template?
If you're looking for broader support, we also offer toolkits and library bundles that include this template, along with other HR templates and policies for fully managing your situation. These may be more cost-effective if you need deeper advice.
