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This questionnaire collects specific job-related information about a post, and relevant health information about the new starter.
[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:
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
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.
Yes. This template has been designed for organisations of all sizes, including small businesses, charities and growing employers. It follows UK employment law best practice and can be adapted to suit your organisation.
Yes, 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.
Yes, we highlight the areas of the document 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.
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.
If you're looking for broader support, we also offer toolkits and library bundles that include the Pre-employment medical questionnaire form template, along with other HR templates and policies for fully managing your situation. These may be more cost-effective if you need deeper advice.
AI-generated templates can be useful as a starting point, but they may not reflect current UK employment legislation, your organisation's specific circumstances, or the wider HR process. This professionally drafted template has been prepared using current UK employment law and HR best practice, helping reduce the need for significant amendments.
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