Pre-employment medical questionnaire 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
[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 choose 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
