Job Application Form Page 6
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6Medical information (you may be referred for a medical examination as a result of the information
provided here)
Question
Yes
No
Please provide details:
Have you ever suffered from:
-
Heart trouble
-
Lung trouble
-
Stomach trouble
-
Skin disease
-
Ear trouble
-
Eye trouble
Question
Yes
No
Please provide details:
Do you consider yourself to have
Disability?
Have you ever had an operation?
Have you been seriously injured?
Have you received in-patient treatment
for a physical or mental condition?
Have you been refused or dismissed from
employment for health reasons?
Have you received a disability pension?
Have you ever been registered as
disabled?
Have you ever been made ill by your
work?
Have you ever been refused a driving
licence because of ill health?
Do you take medication regularly?
Do you need glasses to read?
Do you suffer from any other ailments?
Declaration:
I confirm that the above information is true and correct and understand that any
misrepresentation will invalidate my application and if employed, could lead to my dismissal. I am
prepared to undergo a medical examination if required and confirm to the best of my knowledge
there are no medical reasons which could prevent me from undertaking the duties of the post.
Signed…………………………………………………………………………….Date…………………………………………
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Parent category: Business