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Pre-employment medical questionnaire form

£7
Word count
Template words
929
Reading time
Reading time
10 mins

This questionnaire collects specific job-related information about a post, and relevant health information about the new starter. 

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What is a Pre-employment medical questionnaire form?

This information can be assessed by OHS advisers or other qualified personnel, who can: 

  1. Assess the candidate's medical capability to do the job for which they have applied: this will include assessing whether there are any statutory and legal reasons why an individual may not carry out particular work: for example, health and safety regulations would mean that a candidate with epilepsy would not be allowed to undertake a post involving driving; and

  2. Provide advice to departments to ensure that none of the role's duties will adversely affect any pre-existing health conditions the candidate has declared.

Applicable legal jurisdictions
In which jurisdictions can this form be used?
Great Britain & NI (United Kingdom), Worldwide

Pre-employment medical questionnaire

[Employees starting jobs that involve work with hazards (e.g. sensitising chemicals, allergens etc) or safety-critical activities (e.g. night work, driving a vehicle etc) must complete and return this medical questionnaire before commencing employment.]

An answer must be provided for all questions. The information will be treated in confidence by the Occupation Health Adviser.

PLEASE COMPLETE IN CAPITAL LETTERS

Position applied for:  

Personal details

Title:  Mr | Mrs | Ms | Mx | Dr | Other
Full Name:  
Address:  
Contact telephone:  
Date of birth:  

GP details

GP name:  
Address:  
Telephone:  

Occupational hazard history

Please note the job titles, dates, and nature of any known hazards to which you have been exposed.  

Medical history

Please complete the following questions by ticking the appropriate box. If the answer is yes, give details including (a) date, (b) amount of time lost from work/school, (c) treatment, as appropriate.

Visual defects/eye conditions (including colour-blindness): Yes | No
Hearing defects/ear conditions: Yes | No
Severe anxiety, depression, other psychiatric disorder: Yes | No
Paralysis or other neurological disorder: Yes | No
Fainting attacks, blackouts, epilepsy or fits: Yes | No
Recurrent headaches, migraine: Yes | No
Vertigo, giddiness or tinnitus: Yes | No
Heart disease, high blood pressure: Yes | No
Asthma, bronchitis, tuberculosis or other chest disease: Yes | No
Peptic ulcer or other digestive or bowel disorder: Yes | No
Liver disorder: Yes | No
Kidney or bladder problems: Yes | No
Gynaecological problems: Yes | No
Recurrent backache, arthritis, rheumatism: Yes | No
Any blood disorder: Yes | No
Eczema, dermatitis, other skin conditions: Yes | No
Diabetes, thyroid or other gland problems: Yes | No
Hayfever, allergies to drugs, animals etc.: Yes | No
Any recurrent infections: Yes | No
Any impairment of immunity to infection: Yes | No
Varicose veins causing trouble: Yes | No
Hernia: Yes | No
Any alcohol or drug related problems or illness: Yes | No
Any other medical condition, physical or mental, not mentioned above: Yes | No

Have you?

Ever undergone a surgical operation or been admitted to hospital for any reason? Yes | No
Had more than 20 days sickness absence in the past 2 years? Yes | No
Ever been, or are a Registered Disabled Person? Yes | No
Received a Disability Pension? Yes | No
Suffered from an Industrial Disease/Accident? Yes | No
Had a chest X-ray in the past 12 months? If so state place / date / result: Yes | No

Present health status

Are you currently attending a doctor? Yes | No
Are you at present on any medication or treatment prescribed by a doctor? Yes | No
Are you a smoker? Yes | No
o you drink alcohol? If so how many units per week? (NB 1 unit is 1/2; pint of beer or 1 medium glass of wine) Yes | No
Do you have any eyesight defects other than those corrected by glasses? Yes | No
Do you have any hearing problems? Yes | No
Do you have any defect of speech or communication problem? Yes | No
Do you have any physical disability necessitating special aids, or requirements for access to premises? Yes | No
Do you have any other relevant health problems? Yes | No
What is your height? ...ft ...ins or ...m
What is your weight? ...st ...lbs or ...kgs

Declaration

  1. I declare that, to the best of my knowledge, the information I have given is correct.
  2. I understand that I may be required to attend a medical examination
  3. I understand that failure to disclose relevant information or giving false information may result in termination of my employment.
Signed:  
Date:  

---

Report from OH physician to management

Employees name:  
Date of birth:  
Job title:  

MEDICAL ASSESSMENT: PRE-EMPLOYMENT

In my opinion, the above is:

[ ] A: Medically suitable for employment in the proposed occupation

[ ] B: Medically unsuitable for employment in the proposed occupation

[ ] C: Medically suitable for employment in the proposed occupation, subject to the following conditions:

Signed:  
Date:  

Version: [1.0]

Issue date: [date]

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