Thomas Cook - Decrease in Medical Fitness - Not absent for health reasons

Thomas Cook - Decrease in Medical Fitness - New diagnosis or medication – remained able to work

The information provided in this questionnaire will be treated confidentially and will not be passed on to your employer. The employer will only be advised of the outcome of the assessment in terms of ‘fit’ or ‘not fit’.

Please note that incorrect or incomplete forms will not be processed and you will be asked to resubmit the questionnaire.


First Name
Last Name
Date of Birth
Staff Number
Telephone Number
Email Address
Have you had a surgical procedure?
Please provide details.
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Details

If you answered yes, please provide details.

Also, please let us know if you are fully recovered from the procedure and if not, what symptoms remain.

Please provide the date and type of surgical procedure and whether there is any planned follow-up.
Have you been diagnosed with a medical condition?
Please provide details.
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Details

If you answered yes, please provide details.

Please provide details regarding name of the condition, date of the diagnosis, whether there are any investigations or follow-up appointments planned.
Have you been prescribed new medication or has your medication changed?
Please provide details.
You hav finished the questionnaire - please review the details and press Submit.
Details

If you answered yes, please provide details.

Please provide details regarding the name of the medication, date when you have started taking it, dosage and whether you are experiencing any side effects

I hereby declare that I have carefully considered the statements made here and that to the best of my knowledge they are complete and correct and that I have not withheld any relevant information or made any misleading statement