Medical Questionnaire

Please disclose any condition which has the potential to affect your ability to carry out your onsite duties safely; without affecting the safety of others on site.

Asthma, bronchitis, emphysema, pleurisy, pneumonia or any other lung disease including TB or pneumothorax disorder *

Yes No

If your answer is yes then please provide details

Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness *

Yes No

If your answer is yes then please provide details

Any problems with bones or joints including back, neck, knee, sciatica, any fracture, or recurrent dislocation of a major joint *

Yes No

If your answer is yes then please provide details

Chest pain, angina, heart disease or breathlessness *

Yes No

If your answer is yes then please provide details

Any visual defect e.g. scotoma, blindness in one eye, night blindness, colour blindness, reduced visual field, blurred vision or detached retina *

Yes No

If your answer is yes then please provide details

Ear infection, discharge, tinnitus, a hearing defect including deafness *

Yes No

If your answer is yes then please provide details

Any metabolic disorder including diabetes, thyroid and adrenal gland disease or other glandular disorder *

Yes No

If your answer is yes then please provide details

Do you have any Physical condition or illness that could prevent you from attending work for a lengthy period of time? *

Yes No

If your answer is yes then please provide details

Current treatment. Are you currently attending a hospital/GP for treatment or waiting for an appointment? *

Yes No

If your answer is yes then please provide details

Do you have a disability which may affect your ability to undertake the position you have applied for? The Disability Discrimination Act 1995 defines a person with a disability as "A physical or mental impairment which has a substantial adverse long term effect on his or her ability to carry out normal day to day activities" *

Yes No

If your answer is yes then please provide details

Do you have any condition that could affect your ability to work night shifts? *

Yes No

If your answer is yes then please provide details

Are you currently taking any prescribed tablets or medication or receiving injections (excluding contraception or HRT)? *

Yes No

If your answer is yes then please provide details

Do you have any unspent criminal convictions? *

Yes No

If your answer is yes then please provide details

I declare that the information I have given is true and correct and I consent to this data being held on a computer or in a manual filing system in accordance with the confidentiality requirements of the Data Protection Act 1998.

Date *

format (dd/mm/yyyy)

If any of this information changes whilst I am employed by/return to work for Headley Professional Recruitment LTD, I will notify a member of staff immediately. Please be aware that any false information given could result in your contract being terminated.