Medical Questionnaire Form - Home

Before completing this form, please read the accompanying guidance notes. Please write clearly in black ink or type.

2. GENERAL PRACTITIONER’S DETAILS

3. EQUALITY ACT 2010

Do you have a disability which may affect your ability to undertake the role of Health Care Assistant or which requires special arrangements?

Yes No

The Equality Act 2010 defines a person with a disability as “A physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.”

If yes, what facilities/adjustments/equipment might enable you to perform the role?

4. PAST MEDICAL HISTORY

Have you ever suffered, or do you currently suffer, from any serious illnesses which may affect your work? If YES, please give details.

Yes No

Do you currently take any prescribed medications that make you dizzy or drowsy? If YES, please give details.

Yes No

Is your eyesight ok (with glasses or contact lenses if needed) for all normal work purposes? If NO, please give details.

Yes No

Is your hearing in each ear ok (with a hearing aid if needed) for all normal work purposes? If NO, please give details.

Yes No

Have you suffered, or do you currently suffer, from any form of Repetitive Strain Injury (RSI)? If YES, please give details.

Yes No

Have you ever left a job or had to be medically retired due to ill health? If YES, please provide details.

Yes No

Please list how many days you have been absent from work, school, college etc in the last three years due to sickness. For each absence please also indicate the dates and the reason.

Number of days absence

Dates of absence (dd/mm/yy)

Reason (please state if related to a disability)

I declare that the information given in this questionnaire is true and complete. I understand that any misleading information or any omissions will be sufficient grounds for termination of my employment. I will notify you immediately if any of my answers change on my completed questionnaire. I do/do not give permission to my General Practitioner to disclose relevant information to the HR department in accordance with the Access to Medical Records Act 1988. I do/do not wish to see my General Practitioner’s comments before the questionnaire is returned to the HR manager. I do/do not want to know if I am at risk of early ill-health retirement.

Signature of applicant:

The information provided by you on this form as an applicant will be stored either on paper records or a computer system in accordance with the Data Protection Act 1998 and will be processed solely in connection with the recruitment process.

CONFIDENTIAL

1. PERSONAL DETAILS

2. GENERAL PRACTITIONER’S DETAILS

3. EQUALITY ACT 2010

4. PAST MEDICAL HISTORY

5. SICKNESS ABSENCE

6. DECLARATION

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