EXAMPLE QUESTIONNAIRE

EXAMPLE Pre-Employment Health Screening Questionnaire

You can be assured that the information will remain confidential to the Occupational Health Service and Doctorcall and will not be given to anyone else without your written permission.

It is important that your answers are accurate and that you do not withold any facts, not only to ensure that the company complies with legislation but for your own health and safety.

Depending on your answers and the nature of your proposed work you may be asked to attend for further screening before any offer of employment is confirmed.

We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. You may be contacted by the OH team.


Title
If 'other' please enter here
Surname
First Name
Date of Birth
Email Address
Home Address

Post Code
Mobile Telephone Number
Other Telephone Number
Job Role Applied For
Location
Type of Assessment
Job Title
Department
Have you been employed in the last 12-months?
Please provide details of your last 3 jobs
Previous job #1

Previous job #2

Previous job #3

Do you have any kind of medical condition which affects your fitness to work?
Have you ever had to give up or change a job for medical reasons?
Do you have any special needs requiring support in employment?
Have you ever had to notify the DVLA of a medical condition?
Is there any other information which Occupational Health should be aware of that will assist in assessing your fitness for employment?
Have you ever been admitted to hospital, or attended as an outpatient in the last 3 years or are you currently on a waiting list?
Are you currently taking any form of medication, whether prescribed by a doctor or not?

Other than oral contraceptive

Have you consulted your GP or hospital specialist in the last 3 years?
Have you used the services of any professional complementary to medicine in the last 3 years?

Homeopathy, physiotherapy, chiropractic

Have you ever had a mental health problem which required hospitalisation, medication or referral to a psychiatrist, psychologist or counselor?
Further information

If you have ansswered 'Yes' to any of the above questions, please provide details here:

How many days have you been absent from work due to illness in the last 2 years?

Please give dates, number of occasions, total number of days and reasons.



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 >

I hereby declare that the foregoing information is true and correct to the best of my knowledge.

In accordance with the Data Protection Act 1998 the information submitted here will be used for medical purposes only and will not be released to anyone who does not require it for this purpose. Any recommendations made on the basis of this assesment may be forwarded as necessary. The information will be placed in your Occupational Health file.

To send your responses, click Submit below.