Medical Questionaire
PRESTIGE CARE CONFIDENTIAL MEDICAL QUESTIONNAIRE
Name:............................................................................... Date of birth:................................
Please complete this questionnaire. As a result of the information given, you may be referred to your G.P. for a medical examination to ascertain your fitness for the duties involved in the post applied for.
To the best of my knowledge the information is correct, and I understand that if I have knowingly given false information I would be liable to dismissal. Signed:.............................. ......... Date:...............
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Please tick no or yes |
No |
Yes |
If yes, please give details: |
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Have you ever suffered from: |
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Frequent headaches |
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Lung or breathing problems |
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Rheumatism or arthritis |
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Stomach trouble |
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Heart or chest problems |
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Tiredness or weariness |
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Swollen legs or ankles |
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Varicose veins |
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Back or muscolo-skeletal problems in any way |
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High blood pressure |
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Skin disease |
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Ear trouble |
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Eye trouble |
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Any other ailment |
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Have you ever: |
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Been registered disabled |
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Been seriously injured |
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Been made ill by your work |
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Been refused a drivers licence because of ill health |
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Been refused employment, dismissed from employment or left employment for health reasons |
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Had an operation |
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Received a disability pension |
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Received in patient treatment for a physical or mental health condition |
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Do you: |
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Wear hearing aids |
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Wear glasses, lenses, etc. |
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Take regular medication |