Pre Employment Health Questionnaire Template
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4Pre-employment health questionnaire
PRIVATE AND CONFIDENTIAL
Please complete and return this form as directed.
The health of each candidate is considered individually and no decision to reject a candidate on medical grounds
will be made without a medical examination or medical advice being sought.
You should notify us immediately if you have any serious illness after completing this form and before you take up
the appointment offered as a result of your application.
If you give any information that you know is false – or you withhold any information – your application may be
rejected (or, if already appointed, you may be dismissed).
SECTION ONE – RECRUITMENT – TO BE COMPLETED BY THE EMPLOYER
Company
Department
Name of person responsible for recruitment
Name and contact telephone number of person to whom medical clearance should be returned
Job title/position applied for
Typical tasks associated with this job
In which department will the employee be working?
Proposed date of joining company
o
Please tick boxes regarding job hazards
None
o
o
Heavy physical work or manual handling
Repetitive upper limb movements
o
o
Extremes of temperature
Noisy environment
o
o
Respiratory or skin hazards
Vocational driving (HGV/LGV/PCV/Fork lift)
o
o
High mental demands
Night work
Other hazards – especially other chemical hazards -- please specify
SECTION TWO – TO BE COMPLETED BY THE EMPLOYEE
Surname
Date of birth
Forename
Sex
Male / female
Home address
Post code
Contact tel number
Please complete the next page
Pre-employment health questionnaire Form 1000
05/03
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