Pre-employment medical questionnaire form template
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The purpose of this form
🔒 The form template
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:
- 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.
10 mins
What is a Pre-employment medical questionnaire form?
The purpose of this Pre-employment medical questionnaire form template is to provide you with a flexible and customisable document to serve as a robust and effective starting point for you.
By using our Pre-employment medical questionnaire form template, you can streamline your process, maintain consistency and accuracy, and save time, and it can be easily adapted to fit your specific scenario.
Great Britain & NI (United Kingdom), Worldwide
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 |
Gynaecological problems: | Yes | No |
Recurrent backache, arthritis, rheumatism: | Yes | No |
Any blood disorder: | Yes | No |
Eczema, dermatitis, other skin conditions: | Yes | No |
Diabetes, thyroid or other gland problems: | Yes | No |
Hayfever, allergies to drugs, animals etc.: | Yes | No |
Any recurrent infections: | Yes | No |
Any impairment of immunity to infection: | Yes | No |
Varicose veins causing trouble: | Yes | No |
Hernia: | Yes | No |
Any alcohol or drug related problems or illness: | Yes | No |
Any other medical condition, physical or mental, not mentioned above: | Yes | No |
Have you?
Ever undergone a surgical operation or been admitted to hospital for any reason? | Yes | No |
Had more than 20 days sickness absence in the past 2 years? | Yes | No |
Ever been, or are a Registered Disabled Person? | Yes | No |
Received a Disability Pension? | Yes | No |
Suffered from an Industrial Disease/Accident? | Yes | No |
Had a chest X-ray in the past 12 months? If so state place / date / result: | Yes | No |
Present health status
Are you currently attending a doctor? | Yes | No |
Are you at present on any medication or treatment prescribed by a doctor? | Yes | No |
Are you a smoker? | Yes | No |
o you drink alcohol? If so how many units per week? (NB 1 unit is 1/2; pint of beer or 1 medium glass of wine) | Yes | No |
Do you have any eyesight defects other than those corrected by glasses? | Yes | No |
Do you have any hearing problems? | Yes | No |
Do you have any defect of speech or communication problem? | Yes | No |
Do you have any physical disability necessitating special aids, or requirements for access to premises? | Yes | No |
Do you have any other relevant health problems? | Yes | No |
What is your height? | ...ft ...ins or ...m |
What is your weight? | ...st ...lbs or ...kgs |
Declaration
- I declare that, to the best of my knowledge, the information I have given is correct.
- I understand that I may be required to attend a medical examination
- I understand that failure to disclose relevant information or giving false information may result in termination of my employment.
Signed: | |
Date: |
---
Report from OH physician to management
Employees name: | |
Date of birth: | |
Job title: |
MEDICAL ASSESSMENT: PRE-EMPLOYMENT
In my opinion, the above is:
[ ] A: Medically suitable for employment in the proposed occupation
[ ] B: Medically unsuitable for employment in the proposed occupation
[ ] C: Medically suitable for employment in the proposed occupation, subject to the following conditions:
Signed: | |
Date: |
Version: [1.0]
Issue date: [date]
Why buy our Pre-employment medical questionnaire form template?
- It's easily editable and implementable, saving you time and money
- It's designed by CIPD accedited Chartered HR practitioners with operational experience in this area
- You will maintain compliance with ACAS guidelines, legislation, and industry best practices
- Email notifications for any updates made to this template or its accompanying materials
- 12 months of unrestricted access without any additional costs (any update in that period is free to you)
- A 25% discount on all library, toolkit, and template purchases/renewals