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Forms > Employee Health Declaration Form

Employee Health Declaration Form

Title*:
Surname*:
First Names*:
Surname At Birth*:
Former Names*:

Please answer the following questions, giving dates and full details where appropriate:

Are you in good health at present?
YesNo
Are you at present attending a doctor or hospital for any reason?
YesNo
Are you taking any medicines or tablets or having any other treatment regularly prescribed by a doctor or hospital?
YesNo
Have you now or in the past had any disease other than normal childhood illnesses, colds and flu?
YesNo
Have you ever had any of the following:
Depression, nerves or similar illnessesDiabetesThrombosisBack problemsBlack outs epilepsy or faintsTuberculosis

Have you ever had any of the following:
Contact with anyone with TuberculosisAn illness which causes problems with mobilityHeart disease or disorderHave you been admitted to hospital in the last two years or have suffered any serious illness in the last five years?

If you have answered yes to any of the above please give details.

How many days of sickness leave have you had in the last 2 years?
Please give reasons.

Please give details of your General Practitioner

Name:
Telephone:
Address:


Print Name:
Date: