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Medical Questionnaire Targetex

This document contains a pre-employment health questionnaire for College Freight Ltd. The 3 page form asks applicants to provide medical history details, current health conditions, medications, smoking and drinking habits. It notes that a disability will not preclude employment if the job can be done safely. All information will be kept confidential and a medical exam may be required. The applicant must sign declaring the information true or their employment can be terminated for withholding or false details.

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Peadar Proinsias Ó Dubhda
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53 views2 pages

Medical Questionnaire Targetex

This document contains a pre-employment health questionnaire for College Freight Ltd. The 3 page form asks applicants to provide medical history details, current health conditions, medications, smoking and drinking habits. It notes that a disability will not preclude employment if the job can be done safely. All information will be kept confidential and a medical exam may be required. The applicant must sign declaring the information true or their employment can be terminated for withholding or false details.

Uploaded by

Peadar Proinsias Ó Dubhda
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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College Freight Ltd t/a Target Express Ireland

HR08 Medical Questionnaire

PRE-EMPLOYMENT HEALTH QUESTIONNAIRE

This form is used by the Company to assist in assessing fitness for employment. A disease or disability will not necessarily preclude you from being employed so long as you can do the job without risk to yourself or colleagues. The information provided will be treated with the strictest confidence. You may be required to attend a medical examination at the Companys expense. All sections of this form must be completed in full using BLOCK capitals

Title

Mr / Mrs / Ms / Miss Other

Surname Date of Birth

Forenames Home address

Contact Numbers Name & address and contact numbers of Doctor

Please state how many days sickness absence you have taken within the past 2 months, indicating the length of each separate period of absence.

MEDICAL HISTORY
Please complete the following questions by ticking the appropriate box. If the answer is YES then please provide details in the space provided at the end of the questionnaire. Have you ever suffered from any of the following illnesses?

Visual defects/eye conditions (including colour blindness) Hearing defects/ear conditions Severe anxiety, depression, other psychiatric disorder Fainting attacks, blackouts, epilepsy or fits Recurrent headaches, migraines Vertigo, giddiness or tinnitus Heart disease, high blood pressure Asthmas, bronchitis, tuberculosis or other chest disease Liver disorder

Recurrent back ache, arthritis, rheumatism Any blood disorder Eczema, dermatitis, other skin conditions Diabetes, thyroid or other gland problems Hay fever, allergies to drugs, animals etc Any alcohol or drug related problems or illnesses Any other medical condition, physical or mental, not mentioned above. Peptic ulcer or other digestive bowel disorder Kidney or bladder problems If ticked yes to any, please specify

College Freight Ltd t/a Target Express Ireland

HR08 Medical Questionnaire

Have you? Ever undergone a surgical operation? Had more than 20 days sickness in the past 2 years? Ever been, or are a Registered Disabled Person? Suffered from an industrial Disease / Accident? Are you currently attending a doctor? Are you at present on any medication or treatment prescribed by a doctor? Are you a smoker? If yes please give details of what Do you drink alcohol? If so how many units per week? Do you have any eye sight defects other than those corrected by glasses?
DECLARATION: 1. 2. 3.

Do you have any defect of speech or communication problems? Do you have any physical disability necessitating special aids, or requirements for access to premises? Do you have any other relevant health problems? If ticked yes to any, please specify:

I DECLARE THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION I HAVE GIVEN IS CORRECT I UNDERSTAND THAT I MAY BE REQUIRED TO ATTEND A MEDICAL EXAMINATION I UNDERSTAND THAT FAILURE TO DISCLOSE RELEVANT INFORMATION OR GIVING FALSE INFORMATION MAY RESULT IN TERMINATION OF MY EMPLOYMENT.

NAME:__________________________________ DATE:___________________________________ SIGNATURE:_____________________________

For office use: Date received: VIP updated: Y/N

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