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Recruitment: Medical questionnaire (form)

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Source: XpertHR P&D

Date: 22/07/2005

Publisher: XpertHR

Recruitment: Medical questionnaire (form)

TOPICS:

recruitment	selecting staff
terms, conditions and employee rights	general rights
equal opportunities	disability

AUTHOR: Chris Schofield

Form wording:

Surname:
Forenames:
Vacancy reference number:
Address:
Appointment applied for:		National insurance number:
Name and address of own doctor:		National Health Service number:

Please answer all the following questions by circling the appropriate word: if the answer is yes, circle yes; if it is no, circle no.

	Questions
1	Do you have any physical or mental impairment that could be classed as a disability under the Disability Discrimination Act 1995?	Yes	No
2	Have you ever received compensation or a disability pension?	Yes	No
3	Are there any medical reasons why you should not do shift work?	Yes	No
4	Are you able to carry out strenuous physical work including climbing ladders, working from scaffolding, bending, lifting and carrying?	Yes	No
5	Have you ever had to give up any previous job for medical reasons?	Yes	No
6	Have you been off work continuously for more than a month during the last five years?	Yes	No
7	Have you ever had any operations requiring hospital admission for five or more days?	Yes	No
8	Is your eyesight normal (with glasses if worn)?	Yes	No
9	Is your hearing normal?	Yes	No
10	(a) Do you regularly take tablets or medicine? (b) If so, what do you take?	Yes	No
11	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
12	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
13	Do you suffer from any of the following?
	Migrane 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
14	If you have circled any answers as Yes for questions 1 to 13, please give very brief details below:

15	Have you ever had any other serious illness? If yes, please give very brief details below.

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