Section 6 Health Questionnaire
PLEASE COMPLETE ALL FIELDS Surname: Forenames(s): Date of Birth:
Have you ever suffered from any of the following?
Additional Information
Asthma or Bronchitis NoYes
Back injury, pain or problems NoYes
Chickenpox, German Measles, Rheumatic Fever, Dysentery, Tuberculosis, Typhoid, Poliomyelitis, Jaundice or Hepatitis NoYes
Chest pains, heart condition or high blood pressure NoYes
Depression, break-down or mental illness NoYes
Dermatitis, skin allergies, eczema or psoriasis NoYes
Diabetes, thyroid or other gland problems NoYes
Epilepsy, fits or migraines NoYes
Eye-sight impairment or problems, Do you wear glasses or contact lenses? NoYes
Hearing problems or ear infections NoYes
Gastric problems, ulcers or irritable bowel syndrome NoYes
Varicose veins or circulatory problems NoYes
Further Questions
Answer
Do you smoke? NoYes
How many units of alcohol do you consume on a weekly average?
Have you ever had salmonella or food poisoning?NoYes
Have you ever suffered from, or come into contact with, Hepatitis B NoYes
Have you ever had any major operations? NoYes
Are you currently receiving any treatment or medication? NoYes
Have you ever been medically unfit for any reason? NoYes
Are you registered under the Disabled Persons Act?NoYes
Are you, or have you been, in receipt of a disability pension? NoYes
Notice: Serenity Always Healthcare requires certain information prior to candidates commencing employment, to ensure performance requirements for the position are met and a reliable service is provided. This information is to ensure compliance with relevant Health and Safety regulations. The information is also required in order to establish whether any reasonable adjustments may need to be made to assist you in performing your duties, in accordance with the Disability Discrimination Act 1995. All information provided is kept confidential and used only for the purposes detailed above in compliance with the Data Protection Act 1998.
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