Health Declaration - Confidential

The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. 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. Before health clearance is given for assignment you may be contacted or need to be seen by an occupational health advisor or physician. Your record will be held on file and may be subject to audit.

"*" indicates required fields

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Personal Information

Name*

Title First Last

Date of birth*

Home Address*

Street Address Address Line 2 City Postcode Country

Mobile*

Home Telephone

Work Telephone

GP Information

GP Name*

Surgery / Practice Name*

Surgery / Practice Address*

Street Address Address Line 2 City Post code Country

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Do you have any back problems or other musculo-skeletal problems which will cause difficulty in bending, lifting or standing for long periods?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Do you have a history of anxiety, depression, psychiatric disorder, stress related problems, eating disorders, drug/alcohol misuse, self harm or overdose?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Are you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide further details of the condition, treatment and dates.*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Do you think you may need any adjustments or assistance to help you to do the job?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Tuberculosis (Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006))

Have you lived continuously in the UK for the last year (include Holidays/Vacations)?*

Yes

Additional Information (If you have answered no please provide additional information below)*

Have you had a BCG vaccination in relation to Tuberculosis?*

Yes

Date*

Do you have any of the following?*

A cough which has lasted for more than 3 weeks

Unexplained weight loss

Unexplained fever

Have you had tuberculosis (TB) or been in recent contact with open TB?

None of the above

Chicken Pox or Shingles

Have you ever had chicken pox or shingles?*

Yes

Date*

IMMUNISATION HISTORY

Have you had any of the following immunisations?

Triple vaccination as a child (Diphtheria/Tetanus/Whooping cough)*

Yes

Date*

Polio*

Yes

Date*

Tetanus*

Yes

Date*

Hepatitis B (If Yes is ticked please give dates below)*

Yes

Course Dose 1*

Dose 2

Dose 3

Booster Dose 1

Dose 2

Dose 3

Have you been vaccinated against COVID-19?*

Yes

Course Dose 1*

Name of Vaccine*

Course Dose 2

Name of Vaccine

Last Booster

Name of Vaccine

Please submit your COVID-19 pass*

Max. file size: 64 MB.

You can apply for your COVID-19 (International Pass) by going to: https://www.nhs.uk/conditions/coronavirus-covid-19/nhs-covid-pass/get-an-nhs-covid-pass/

COVID-19

Have you previously tested positive for COVID-19?*

Yes

Date*

COVID 19 and Existing Health Conditions (please mark all that apply)*

Has a member of your immediate family (parent under 70, sibling, child) been in ITU or died with Covid-19?

Do you have Stomach or intestinal disorders?

Do you have any condition which causes difficulties sleeping?

Do you have any chronic chest disorders, especially if night-time symptoms are troublesome?

Do you have any medical condition requiring medication to a strict timetable ?

Are there any other health factors that might affect fitness at work?

None of these apply

Additional Information (If you have answered yes please provide additional information below)*

Are you aged...*

49 and under

50 - 59

60 - 69

Sex at birth - were you born a Male?*

Yes

Do you identify as on of the BAME or Mixed-race groups?*

Yes

Are you on any treatment for Hypertension (high blood pressure), Atrial Fibrillation (Irregular heart rate), Heart Failure, Previous MI (had a heart attack), had a stroke, or Transient Ischemic Attack (mini stroke)?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Do you have Diabetes Mellitus Type 1 or 2?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Do you have chronic lung disease (including asthma, COPD, interstitial lung disease?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Do you have Chronic kidney disease (any stage 1 – 5)?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Do you have Sickle cell trait, Thalassaemia trait or other hemoglobinopathy?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Do you have a BMI that is more than 30 or your waist circumference is: South Asian female more than 33 inches (84cm). other BAME or white female more than more than 34.5 inches (88cm) South Asian Male more than 35 inches (89cm); Other BAME or white Male more than 40 inches (102cm)*

Yes

Night Work

Existing Health conditions (please mark all that apply) If you have answered 'yes' to any of the following questions, you may be asked to see a doctor or nurse for further assessment.

Do you have Diabetes Mellitus Type 1 or 2?*

Yes

Do you have Stomach or intestinal disorders?*

Yes

Do you have Heart or circulatory disorders?*

Yes

Do you have any condition which causes difficulties sleeping?*

Yes

Do you have any chronic chest disorders, especially if night-time symptoms are troublesome?*

Yes

Do you have any medical condition requiring medication to a strict timetable?*

Yes

Are there any other health factors that might affect fitness at work?*

Yes

Additional Information (If you have answered yes please provide additional information below)*

Declaration

I will inform my employer if I am planning to or leave the UK for longer than a three month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Name*

First Last

Signature*

Your Name
Your Name
Your Name

Date*