Pre-employment medical questionnaire form document template

Employees starting jobs that involve work with hazards (eg sensitising chemicals, allergens etc) or safety-critical activities (eg night work, driving a vehicle etc) must complete and return the new starter medical questionnaire before commencing employment. This questionnaire collects specific job-related information about a post, and relevant health information about the new starter. This information is then assessed by OHS advisers who can: 

(i) 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 

(ii) 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.

£3.95

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

Title (circle):

Full name:

Address:

Contact telephone:

Date of birth:

 

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.

Have you ever suffered from any of the following illnesses?

Visual defects/eye conditions (including colour-blindness):

[Yes] [No] If yes, please give details:

.....................................................................................

Hearing defects/ear conditions:

[Yes] [No] If yes, please give details:

.....................................................................................

Severe anxiety, depression,

731 words. Last updated on 28/11/18. ©2020 HRDocBox.