Monday, October 22, 2018
   
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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:...............

 

Please tick no or yes

No

Yes

If yes, please give details:

Have you ever suffered from:

     

Frequent headaches

     

Lung or breathing problems

     

Rheumatism or arthritis

     

Stomach trouble

     

Heart or chest problems

     

Tiredness or weariness

     

Swollen legs or ankles

     

Varicose veins

     

Back or muscolo-skeletal problems in any way

     

High blood pressure

     

Skin disease

     

Ear trouble

     

Eye trouble

     

Any other ailment

     

Have you ever:

     

Been registered disabled

     

Been seriously injured

     

Been made ill by your work

     

Been refused a drivers licence because of ill health

     

Been refused employment, dismissed from employment or left employment for health reasons

     

Had an operation

     

Received a disability pension

     

Received in patient treatment for a physical or mental health condition

     

Do you:

     

Wear hearing aids

     

Wear glasses, lenses, etc.

     

Take regular medication