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Recruitment documents Job offer documents

Pre-employment medical questionnaire form template

Reviewed 15 March 2021

This questionnaire collects specific job-related information about a post, and relevant health information about the new starter. This information can then be assessed by OHS advisers or other qualified personnel, who can: 

  1. 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
  2. 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.

Pre-employment medical questionnaire

[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

Personal details

Title:  Mr | Mrs | Ms | Mx | Dr | Other
Full Name:  
Address:  
Contact telephone:  
Date of birth:  

GP details

GP name:  
Address:  
Telephone:  

 

Position applied for:  

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 | No
Heart disease, high blood pressure: Yes | No
Asthma, bronchitis, tuberculosis or other chest disease: Yes | No
Peptic ulcer or other digestive or bowel disorder: Yes | No
Liver disorder: Yes | No
Kidney or bladder problems: Yes | No
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