Pre-Placement Health Questionnaire

The business that you have applied to for employment is committed to the Health, Safety and general wellbeing of its employees. As part of these commitments, this Pre- Placement Health Questionnaire is required to be completed by all employees prior to commencement of employment. As every employer is bound by The Health and Safety at Work Regulations 1974. Your employer is required to assess 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 role, but also the fitness of the employee to carry out that role. In addition, The Equality Act 2010 requires making, where appropriate, reasonable adjustments.

This Pre-Placement 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 legislation. In the vast majority of cases, this questionnaire will be sufficient for Occupational Health to confirm medical suitability for employment in the proposed occupation. However, in a very few instances, occupational health may need to make further enquiry of an individual. A medical examination by your GP/medical specialist/occupational health may be required based on the outcomes of the Pre-Placement Questionnaire.

Confidentiality
You will be made aware of the outcome of the pre-placement questionnaire by your prospective employer once it has been received and processed by occupational health, as a certificate will be sent to your employer. This will not contain any medical information that you have provided without your consent. Further discussion with you and occupational health may be required depending on the outcomes of your pre placement questionnaire. If you are not contacted by Occupational Health, a certificate of fitness for role will be issued to your employer within 3 – 5 days of receiving this document.

If you have any issues with completing and returning this form please discuss them with your relevant contact pre-completing this pre-placement medical assessment for the role that you have applied for.

Pre-Employment Health Questionnaire

This questionnaire needs to be completed in full as only full questionnaires can be processed. The information will be treated in confidence by occupational health. 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?

Anxiety, depression, other mental wellbeing issues
Paralysis or other neurological disorder
Fainting attacks, blackouts, epilepsy or fits
Recurrent headaches, migraine
Vertigo, giddiness or tinnitus
Heart disease, high blood pressure
Breathing issues for example asthma, sleep apnoea, COPD
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
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 night work
Do you have any other relevant health problems that have not been previously documented

Declaration

Declaration
Require Phone Call
Declined Phone Call
Understand False Disclosure
Do you give consent for a certificate to be sent to your prospective employer?