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
Forenames(s)
Surname
Previous Names (if applicable)
Contact Number
Email Address: (required)
Date of Birth
Home Address

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

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

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

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

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?

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

Are you receiving any treatments or ongoing medication?

​Do you have any allergies?​

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

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

Where you ever discharged from previous employment on medical grounds?

Have you had any of the following:

Yes / No

If Yes, give details with dates

* Arthritis / Rheumatism

* Mental Health Problems

* Alcohol or drug related abuse

* Anaemia or blood disorder

Asthma

* Epilepsy, head injuries, vertigo

* Ear / Eye conditions

Diabetes

* Skin conditions eg. Dermatitis, eczema

* Bronchitis, persistent cough or wheeze

* Difficulties with walking / bending

* Back injury / problems

* Neck injury / problems

* Any other health related problems?

* Heart / Liver or Kidney problems

* Cough which lasted more than 3 weeks

* Unexplained weight loss

* Intermittent fever with night sweats

* Investigation for Tuberculosis

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

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

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)

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

DECLARATION

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 Homecarers Ltd's Privacy Policy.

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Date
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