Health Screening Questionnaire

Private & Confidential

Privacy Notice

This information is collected in the company's legitimate interest to ensure that we meet our duty of care for our employees. The information provided on this form will be used by the organisation to determine if it is safe for you to undertake a work task or if the activities that you are required to undertake will exacerbate any pre-existing medical conditions.

The form will be handled in strict confidence and all information stored according to the requirements of the applicable data protection legislation. Health surveillance during employment may be required. Advice regarding fitness for work will be accessible to management in general terms, but detailed clinical information will not be revealed without consent.

If further information is required from your doctor or health specialist, this will only be obtained with your written consent.

Section A — Personal Details

Surname *

Forename/s *

Address *

Tel no *

Email *

Name and address of personal doctor *

Position *

Section B — Job Involves / May Expose Employees To

Tick all that apply to the role:

Other hazards if applicable

Section C — Health History

Do you have, or have you previously had, any of the following health conditions? *

Tick all applicable conditions:

If you answer 'yes' to the above questions, you may be asked to see a doctor or nurse for further assessment.

Follow-up Questions

Do you have any implanted, body active or inactive medical devices worn (e.g. pacemaker)?

Do you have any other known medical condition/s not mentioned above?

How many days have you been absent from work in the last three years because of illness or physical injury?

Are you currently taking any prescribed medication?

Are you allergic to any medications (e.g. penicillin)?

Please state which medications *

Notes any additional information

Section D — Disabilities

Do you have any disabilities that affect the following? *

Tick all affected areas:

If you answer 'yes' to the question, you may be asked to see a doctor or nurse for further assessment.

Section E — Employee Declaration

I confirm that to the best of my knowledge, the above information is correct. I understand that any failure to disclose information could lead to a re-assessment of my general fitness, which could ultimately lead to the termination of my employment.

Name (block capitals) *

Date

Signature *