PRE-PLACEMENT HEALTH QUESTIONNAIRE

Please complete this form as directed.

All the information that you provide on your health questionnaire will be treated as strictly confidential to Split Dimension Ltd. The purpose of this questionnaire is to assist your employer meet its statutory duty to maintain a safe working environment for all employees and where necessary to meet any obligations under the Equality Act 2010. The information will be used to give an opinion about your fitness for your employment, and to help provide you with assistance to protect your health at work.

Organisation you are applying to work for *

Surname *

Forename(s) *

Date of Birth *

Gender *

Address *

Home Telephone Number

Mobile Telephone Number *

Email Address *

Name of Doctor (GP) *

Doctor's Telephone Number

Doctor's Address *

Position Applied For *

Location

Do you have, or have you had any of the following conditions or health problems? If you answer YES to any of the following please could you provide details with dates at the end of the form.

1. Tuberculosis, pleurisy, asthma, bronchitis, or any other lung complaint? *

2. Heart disease, chest pain, palpitations, high blood pressure? *

3. Circulation problems, including Reynaulds disease? *

4. Gastric disorder, intestinal complaint? *

5. Hernia or Rupture? *

6. Fainting attacks, blackouts, epilepsy or fits? *

7. Mental illness, depression, anxiety, nervous complaint or eating disorders? *

8. Diabetes, thyroid disease or pituitary disorder? *

9. Kidney or bladder complaint? *

10. Arthritis, rheumatism, joint problems or any neck or back trouble? *

11. Do you experience any back, hip, knees elbow, or feet pain at present? *

12. Are you able to undertake all your normal day to day activities outside work? eg sports, hobbies and DIY *

13. Any dermatitis or other skin complaint or allergic condition including latex allergy? *

14. Any hearing loss or ear problems? *

15. Have you ever had an upper limb disorder? eg Repetitive Strain Injury, tenosynovitis *

16. Have you ever sought medical help for alcohol or drug abuse? *

16.1. If you answered 'Yes' to Q16 above, was it... (tick all that apply)

Alcohol

Drugs

16.2 Have you ever been diagnosed with a developmental or learning disability such as Autism, Asperger’s syndrome or Dyslexia? *

17. Have you ever been advised for medical reasons not to do night work or shift work? *

18. Have you ever had any disease or injury arising out of your work? eg deafness, backache, dermatitis, hand arm vibration syndrome or asthma? *

19. Are you in receipt of a disability pension? *

20. Do you have a disability or illness requiring regular medication? *

21. Any eye complaint including recurrent headaches, blurred vision or eye discomfort? *

22. Do you normally wear glasses or contact lenses? *

23. When did you last have an eye test? *

24. Have you ever failed a medical examination of any kind? eg for a job, insurance purposes *

25. Have you ever consulted or been recommended to consult a Specialist? *

26. Are you now on any treatment being prescribed by your Doctor? *

27. How many days have you been absent from work, school or college due to sickness in the last 2 years? *

28. Since you left school, what kind of employment have you worked in the longest? *

29. PLEASE GIVE DETAILS OF JOBS YOU HAVE HAD WHERE YOU WERE EXPOSED TO SPECIFIC HEALTH HAZARDS e.g. noise, chemicals, dust and did you wear any personal protective equipment (PPE) for these jobs?

30. EXTRA MEDICAL DETAILS

Declaration

I declare that the answers provided to the questions above are correct to the best of my knowledge. I understand that, should I conceal relevant information or provide deliberately misleading information about my health on this form, the offer of employment may be withdrawn or that my employment may be terminated. I understand that I may be required to undergo a health or medical examination by the Company's appointed Occupational Health Specialists.

Electronic Signature (please write your name) *

Date *

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