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OCCUPATIONAL HEALTH

Please complete this confidential health questionnaire so we can make sure you are fit for work and aware of any support you may need. All information is treated in strict confidence and handled according to data protection laws.

Do you have any physical or mental impairment that could be classed as a disability under the Equality Act 2010?
Yes
No
Have you ever received compensation or a disability pension?
Yes
No
Are there any medical reasons why you should not do shift work?
Yes
No
Are you able to carry out strenuous physical work including climbing ladders, working from scaffolding, bending, lifting, and carrying?
Yes
No
Have you ever had to give up any previous job for medical reasons?
Yes
No
Have you been off work continuously for more than a month during the last five years?
Yes
No
Have you ever had any operations requiring hospital admission for five or more days?
Yes
No
Is your eyesight normal (with glasses if worn)?
Yes
No
Is your hearing normal?
Yes
No
Do you regularly take tablets or medicine?
Yes
No

Have you ever had any of the following?

Diabetes
Yes
No
Tuberculosis
Yes
No
Angina
Yes
No
Any other heart trouble
Yes
No
Raised blood pressure
Yes
No
Peptic, gastric, or duodenal ulcer
Yes
No
Indigestion for more than one week
Yes
No
Back trouble, lumbago, sciatica, "slipped disc"
Yes
No
Epilepsy, recurring blackout, or fits
Yes
No
Covid
Yes
No
Covid
Yes
No

Have you ever had any of the following during the past five years?

Bronchitis, asthma, pneumonia
Yes
No
Dermatitis, eczema, or any other skin trouble
Yes
No
Dermatitis, eczema, or any other skin trouble
Yes
No

Do you suffer from any of the following?

Migraine or severe recurring headaches
Yes
No
Anxiety, depression, or any other nervous complaint
Yes
No
Fainting attacks or giddiness
Yes
No
Ear trouble, discharging or infected ear
Yes
No
Kidney trouble or urinary infection
Yes
No
Have you ever had any other serious illness?
Yes
No
Have you consulted a doctor about your health during the past 12 months?
Yes
No
Is there any other condition or illness you wish to make us aware of that may require reasonable adjustments to support you?
Yes
No

The company treats personal data collected in this medical questionnaire in accordance with its data protection policy / policy on processing special categories of personal data.

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