New Employee Health Questionnaire

    Guidance notes; please read carefully

    This new employee health questionnaire gives us information which helps us to:

    • Identify any medical condition which could pose a safety risk to you, your colleagues, patients or members of the public.

    • Check that you are not particularly vulnerable to any hazards that your job may contain.

    The medical details you disclose on this form remain confidential to the HR Department and will not be disclosed to anyone else without your explicit consent.

    Personal Details

    Miss/Mrs/Mr/Other

    Home Address

    Forenames(s)

    Surname

    Previous Names (if applicable)

    Contact Number

    Date of Birth

    Email Address: (required)

    Medical History
    It is important that you give a true and full account of any medical problems when asked.
    If the answer to any of the following questions is “Yes” please give details

    Health Question

    Yes / No

    If Yes give details with dates here

     

    Do you have any illness, impairment, disability (physical or psychological) which may affect your work?

    YesNo

    Have you ever had any illness, impairment or disability which may have been caused or made worse by your work?​

    YesNo

    Are you having or waiting for treatment (including medication) or investigations at present?

    YesNo

    Do you need any specific aids or adaptations to assist you at work whether or not you have a disability, including any hearing or visual aids?

    YesNo

    Do you have any allergies which may be made worse by work e.g. latex?

    YesNo

    Are you receiving any treatments or ongoing medication?

    YesNo

    ​Do you have any allergies?​

    YesNo

    Have you lost time at work/college/school due to illness in the last 2 years?

    YesNo

    Have you ever suffered an injury at work requiring time off from work?

    YesNo

    Where you ever discharged from previous employment on medical grounds?

    YesNo

    Have you had any of the following:

    Yes / No

    If Yes give details with dates here

     

    * Arthritis / Rheumatism

    YesNo

    * Mental Health Problems

    YesNo

    * Alcohol or drug related abuse

    YesNo

    * Anaemia or blood disorder

    YesNo

    * Asthma

    YesNo

    * Epilepsy, head injuries, vertigo

    YesNo

    * Ear / Eye conditions

    YesNo

    * Diabetes

    YesNo

    * Skin conditions eg. Dermatitis, eczema

    YesNo

    * Bronchitis, persistent cough or wheeze

    YesNo

    * Difficulties with walking / bending

    YesNo

    * Back injury / problems

    YesNo

    * Neck injury / problems

    YesNo

    * Heart / Liver or Kidney problems

    YesNo

    * Any other health related problems?

    YesNo

    Have you had any of the following:

    Yes / No

    If Yes give details with dates here

     

    * Cough which lasted more than 3 weeks

    YesNo

    * Unexplained weight loss

    YesNo

    * Intermittent fever with night sweats

    YesNo

    * Investigation for Tuberculosis

    YesNo

    * A close family member / friend with whom you share a home diagnosed with TB

    YesNo

    * Have you been diagnosed with COVID? If so when? Have you had any lasting symptoms and if so, what?

    YesNo

    Have you lived continually in the UK for the last 5 years?
    - If no please list all the countries you have lived in for over a month during this time and advise if you have had a chest x-ray report since arriving in UK?

    (Please attach a copy of the report)

    YesNo

    Please give further information on any YES answers from the above questions.

    Decleration

    Before signing this declaration please ensure you have answered all the questions as instructed providing further details as required. Please ensure the consent form is also signed and fully completed.

    1. I acknowledge that my personal details will be stored both electronically and manually by the HR Department in accordance with the Data Protection Act 2018.

    2. If I have any concerns about how this information is handled I will contact the HR Manager.

    3. I declare that the information provided by me in this entire form is true and complete to the best of my knowledge and belief.

    4. I understand that if any recommendations to my employer are necessary as a result of this new employee health assessment, the HR Manager will discuss the recommendations with me before making them to my employer.

    5. I give consent to the HR Manager to make recommendations to my employer; I do / do not wish to see a written copy of the recommendations before my employer. (please delete as appropriate)

    By submitting this form, you are agreeing to Starcare Ltd's Privacy Policy.

    Agree? (required)YES

    Date

    By using this form you agree with the storage and handling of your data by this website.

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