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 (required)

    Surname (required)

    Forename(s) (required)

    Gender (required)
    MaleFemale

    Address (required)

    Home Telephone Number (required)

    Mobile Telephone Number

    Date of Birth (required)

    Name of Doctor (GP) (required)

    Doctor's Address (required)

    Doctor's Telephone Number

    Position Applied For (required)

    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?
    YesNo

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

    3. Circulation problems, including Reynaulds disease?
    YesNo

    4. Gastric disorder, intestinal complaint?
    YesNo

    5. Hernia or Rupture?
    YesNo

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

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

    8. Diabetes, thyroid disease or pituitary disorder?
    YesNo

    9. Kidney or bladder complaint?
    YesNo

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

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

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

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

    14. Any hearing loss or ear problems?
    YesNo

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

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

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

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

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

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

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

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

    22. Do you normally wear glasses or contact lenses?
    GlassesContact 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
    YesNo

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

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

    27. How many days have you been absent from work 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 information

    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) (required)

    Date (required)