Fitness to work / Annual Health Questionnaire

The company/business that you have applied to for employment is committed to the Health and Safety of its employees. As part of these commitments, this annual Health Questionnaire is required to be completed by all employees prior to commencement of employment and at regular intervals as every employer is bound by The Health and Safety at Work Regulations 1974. We are required to make assessments of potential risks and hazards to which employees may be exposed to at work, and a concise risk assessment involves considering not only the nature of the job, but also the fitness of the employee to carry out that role. In addition, The Equality Act 2010 requires to make, where appropriate, reasonable adjustments to enable a suitably qualified candidate to undertake employment.

This health questionnaire, is supplemented where necessary by a further medical assessment, by telephone or face to face assessment to fulfil any legal responsibilities in respect of the above two pieces of legislation. In the vast majority of cases, this questionnaire will be sufficient for the Occupational Health Adviser to confirm medical suitability for employment. However, in a very few instances, the Medical Adviser may need to make further enquiry of an individual, or a medical examination by your GP/medical specialist may be required based on the outcomes of the this Questionnaire. You will be made aware of the outcome of this questionnaire once the outcome certificate has been received and processed by your employer.

Confidentiality
The completed form will only be seen by Occupational Health, please ensure that you answer all the questions with as much detail as possible as incomplete documentation will most likely cause additional delay.
If you have any issues with completing and returning this form please discuss them with your relevant contact pre-completing this questionnaire.

Strictly Confidential

This questionnaire should be completed as fully as possible. The information will be treated in confidence by the Occupation Health medical professional. If you answer YES to any of the questions please provide as much additional detail as possible to assist with the decision making process and to prevent any time delays.

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Occupational History

Please document below - Nature of Job / Dates of employment / employer / Known hazards to which you have been exposed to.

Please complete the following questions by ticking the appropriate box. If the answer is 'Yes' to any of the below questions please give further detail in the area provided below the question.

Have you ever suffered from any of the following illnesses?

Visual defects/eye conditions (including colour blindness)
Do you have any eyesight defects other than those that are corrected by glasses
Do you have any hearing problems, hearing defects/ear conditions

Have you ever been diagnosed by a medical professional or experienced

Anxiety, depression, other mental wellbeing issues
Paralysis or other neurological disorder
Fainting, epilepsy or fits
Any loss of consciousness or fainting in the last 12 months
Recurrent headaches, migraine
Vertigo, giddiness or tinnitus
Heart disease, high blood pressure
Breathing issues for example asthma, sleep apnoea, COPD, tuberculosis
Have you a recent history of unexplained weight loss, fever, night sweats, persistent cough or coughing up blood
Digestive or bowl issues
Kidney or bladder issues
Gynaecological problems
Backache, arthritis, rheumatism, Any issues with your bones, muscles, ligaments or tendons
Eczema, dermatitis, other skin conditions
Diabetes, thyroid or other gland/endocrine issues
Hayfever, allergies to drugs, animals etc
Any current/previous alcohol or drug related issues or illness
Have you ever undergone a surgical operation or been admitted to hospital for any reason
Have you had more than 10-day's sickness in a row in the past 2 years
Have you ever been, or are registered Disabled
Are you receiving or previously received a Disability Pension
Have you been ill Health Retired (IHR) from any employment
Have you previously or currently suffering from an Industrial Disease and/or Accident
Are you currently attending any doctor and/or hospital appointments
Are you at present on any medication or treatment prescribed by a doctor? If yes please provide name and dose.
Do you have any defect of speech or communication problem
Do you have any physical disability necessitating special aids, or requirements for access to premises
Do you suffer from any health problem which you feel is affected by shift work
Do you have any other relevant health problems that have not been previously documented

Immunisations-proof of immunisations must be provided

Do you work in the Medical or Healthcare Sector?

Declaration

I declare that, to the best of my knowledge, the information I have given within this document is correct.
I understand that I may be required to have a telephone call with occupational health to obtain further information if required. To discuss my responses to this document and it is my responsibility to ensure that I am available when required, if appropriate, within 3 - 5 days of submitting this form on the telephone numbers provided on this document. I will be informed if any further medical information may be required during the telephone assessment.
I decline to have a telephone call with occupational health to obtain further information if required.
I understand that failure to disclose relevant information or giving false information may result in termination of my employment.
Do you give consent for a certificate to be sent to your prospective employer?