Night Worker Questionnaire

Night Worker Questionnaire

Strictly private & confidential


Title
First Name
Surname
Home Address

Date of Birth
Gender
Height
Weight
Employers Name & Address

Job Title & Employing Unit

Total Hours Per Week
As far as you know, do you have any current illness or health problems?
Are you at present having any treatment or taking any form of medication?
Have you seen a doctor or specialist, or had any tests or treatment, within the last five years?
Have you ever had a serious illness or accident, operation or been admitted to hospital?
Is there a history of any particular illness or condition in your family?
Do you know of any condition or health factor which is likely to affect your work attendance (e.g. impending operation / treatment etc)
If the answer to any of the above questions is Yes, please provide full details here
Do you suffer, or have you ever suffered, from any of the following:
If the answer to any of the above questions is Yes, please provide full details here
If you have any other information which you feel is relevant, please provide full details here
I authorise my GP to give a full report of my medical history to Doctorcall, the company’s appointed Medical Advisor, if requested.
Address of GP

Telephone Number of GP
Hours Worked Per Day

Please enter the start time and the end time of your shift on each day

Start time - End time
Start time - End time
Start time - End time
Start time - End time
Start time - End time
Start time - End time
Start time - End time

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 >

Press 'Submit' to send your responses.