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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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For more value, this is also found in our Full library and Job offer templates toolkit
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.
Our templates are developed with UK employment legislation, Acas guidance and HR best practice in mind and are reviewed and updated as relevant requirements change. However, every employment situation is different, so the template should be adapted to the circumstances and checked against the employee's contract and your organisation's procedures before use.
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 format (such as .doc or .xls) 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 can produce a document quickly, but effective HR documentation needs to be more than well-written words. It needs to reflect relevant UK employment law, HR best practice, practical considerations and the circumstances in which it will be used. These resources have been professionally developed around that wider HR context, drawing on extensive practical experience, rather than simply generating a generic document from a prompt.
Darryl Horn, Chartered HR Director
Darryl is a Chartered HR professional with over 25 years' experience in senior HR and employee relations roles.
He has extensive practical experience of managing job offer processes and founded hrdocbox to provide businesses with practical, professionally developed HR resources grounded in UK employment law and best practice.
"Darryl provides support and advice with excellent judgement, and has a strong understanding of people, policies and UK employment legislation."
"He is someone I trust; consistent, dependable, and committed to doing things properly."
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