Pre-employment Questionnaire

First Name *
Family Name *
Photo Upload
Nationality
Date of Birth
Address
Email
Mobile
Landline
Position applied for

Former Occupation(s) Please provide some detail concerning previous jobs in which you have worked.
Date	BRIEF JOB DESCRIPTION	INDICATE WHETHER ANY EXPOSURE TO CHEMICALS, DUST OR NOISE

Please answer yes or no to the following questions. If yes please give details.	Yes	No
1. Do you smoke?			If yes please indicate quantity
2. Do you drink alcohol? (One unit of alcohol is equivalent to one half pint of beer, one glass or wine or one measure of spirit.)			If yes please give quantity per week
3. Do you exercise or play sport?
4. Have you ever been treated for or had counselling/therapy for an addictive disorder involving drugs or alcohol?
5. Have you ever been refused work on health grounds? If yes please give details
6. Have you ever retired or had to give up work on health grounds?
7. Have you attended any doctor for any problem in the past 5 years
8. Are you currently taking medication?
9. Are you having any symptoms or illness investigated currently?
10. Have you ever had an illness or disability that may affect you ability to carry out you duties safely and to a high standard?
11. Have you taken sick leave in the past 3 years?			If so, please give details and length of time off sick

Have you ever had or do you currently have:	Yes	No
12. Pulmonary or respiratory problems? e.g. asthma, bronchitis, wheezing, TB, pneumonia
13. Ear, Nose and throat disorder? e.g. hearing difficulty, difficulty with balance, vertigo, tinnitus, ability to smell, rhinitis, hay fever, voice etc
14. Heart and circulation problems? e.g. anaemia, blood pressure, angina, heart attack, cold or numbness of hands or feet, varicose veins, etc.
15. Diabetes or thyroid disorders etc?
16. Nervous system problems? e.g. epilepsy, fits, faints, blackouts, stroke, headaches, migraine, power loss, numbness, pins and needles etc
17. Eye problem? e.g. visual loss, colour blindness, glaucoma, cataracts, double vision, field defect etc
18. Skin disorder? e.g. eczema, dermatitis, psoriasis, rashes etc
19. Digestive problems? e.g. ulcers, gastritis, irritable bowel, crohn’s disease, ulcerative colitis, pancreatitis, liver disease, gall bladder disease etc
20. Allergies? e.g. medication, chemicals, irritants, cleaning agents, foods etc
21. Musculoskeletal disorders e.g. neck, back and joint problems, slipped discs, trapped nerves, scoliosis, torn ligament or cartilage, rheumatism, fibromyalgia etc.
22. Overuse injury? e.g. tendonitis, tennis elbow, golfers elbow, frozen shoulder, repetitive strain injury (RSI), work related upper limb disorder WRULD) etc
23. Urinary problems? e.g. urinary infections, incontinence, kidney stones, prostatism, prostatitis, etc
24. Female health problems?
25. Tumours – benign and malignant.
26. Psychiatric or psychological problems? e.g. anxiety, depression, panic attacks, nervous breakdown, burnout, schizophrenia, eating disorder, anorexia, bulimia etc
27. Accidents, injuries or illness not already noted?

Declaration:

I understand that the purpose of this pre–employment questionnaire is to confirm that

I am fit for the position I have applied.
I can perform my duties safely and without risk to the health and safety of others.
I can render reliable and productive service for my employer

I declare that the information I have given is true and accurate to the best of my knowledge and that I have not withheld any material facts. I understand that I am responsible for the accuracy or otherwise of the answers above. I understand that if I have knowingly withheld material facts this may affect my appointment.

Tick box to indicate that you understand and agree with the declaration.