Dr Kelly Post-Employment Offer Questionnaire

Dr Kelly Post-Employment Offer Questionnaire

The object of this medical questionnaire is to assess whether individuals may experience potential difficulties in carrying out their duties due to health problems and to advise the company on adjustments or adaptations that may assist this.


About You
Your Address

Date of Birth
Proposed Start Date For New Employment
Have you ever been retired on the grounds of ill health, or made ill by your work?
If “Yes” please specify the factors which led to the above.
Have you had, or are you aware of any condition which could affect your ability to work?
If “Yes” please specify the factors which led to the above.
Do you have a disability or are you registered disabled?
if “Yes” please specify the factors which led to the above.
How many sickness absence days have you had over the last 2 years?
If any, please specify the reasons
Do you smoke?
If “Yes” please specify how many per day on average
Do you, or have you, ever suffered from any of the following
Do you have a visual defect that affects your ability to use a computer?
If “Yes” please specify
Do you wear glasses or contact lenses for specific tasks, eg computer use?
if “Yes” please specify
When did you last have an eye test?
Do you have a hearing problem?
if “Yes” please specify
Any other medical illnesses or investigations not mentioned above?
Are you taking any medication (including contractive pill)?
if “Yes” please specify
Do you have any allergies?
if “Yes” please specify
Do you have any breast, gynaecological or period problems

Females only

if “Yes” please specify
Do you have any 1st degree family illnesses of note?

E.g. veinous thrombosis, stroke, heart disease or other serious condition  (1stdegree relates to parents, siblings or children).

if “Yes” please specify

Your personal information will be held securely and kept private. We will exclusively use the information you submit to provide a quotation. You will not be added to our mailing list without your permission. View privacy policy >

Declaration to be signed by prospective employee

 

I declare that I have fully considered the above questions and the answers are true and correct.

 

I declare that no relevant information has been withheld or any misleading statements made.

I consent to a statement of my fitness for duties, together with a summary of any recommended adaptations, being produced by the assessing doctor and sent to a representative of Human Resources.

I understand that the doctor may require further information from my doctor (a separate consent will be sought should this be requested).