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Medical Questionnaire - Your Name

The document is a pre-employment health questionnaire for a job candidate. It collects information about the candidate's current health status and medical history. The candidate reports their health as good and that they do not smoke, take prescription medications regularly, or have any ongoing medical issues requiring doctor's care. They have also never been absent from work for more than two weeks due to illness or injury.

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novageger24
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72 views3 pages

Medical Questionnaire - Your Name

The document is a pre-employment health questionnaire for a job candidate. It collects information about the candidate's current health status and medical history. The candidate reports their health as good and that they do not smoke, take prescription medications regularly, or have any ongoing medical issues requiring doctor's care. They have also never been absent from work for more than two weeks due to illness or injury.

Uploaded by

novageger24
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PRE-EMPLOYMENT HEALTH MEDICAL

QUESTIONNAIRE

Name of candidate :
Position applied for :

Statement of present health

1. How would you describe your level of present health ?


EXCELLENT

GOOD

FAIR

POOR

Please explain :
2. Do you smoke ?
YES

NO

If YES, please specify quantity of cigarette per day :


3. Do you take non - prescription medicine regularly ?
YES

NO

If YES, please describe.


4. Do you take prescription medicine regularly ?
YES

NO

If YES, please describe :

5. Are you currently under the medical care of a doctor / hospital ?

YES

NO

If YES, please specify :


6. Are you currently on a waiting list for hospital treatment ?
YES

NO

If YES, please specify :


7. How often have you visited your doctor in the last year
Please specify

8. Are you currently required to wear glasses or contact lense ?

YES

NO

If YES, please specify


9. Have you ever been absent from work due to illness/injury for a continuous period in excess of two
weeks ?
YES

NO

If YES, please specify


10. Have you ever had or do you now suffer from any of the following :

- Lung / Chest Problem YES NO


(asthma, TB, pneumonia, bronchitis) Please speficy

- Heart Problem or circulatory disorder YES NO


(heart attack, high blood pressure) Please speficy

- Stomach / Pancreatic Problem YES NO


Please specify

- Kidney disorder YES NO


(kidney stones / infection ) Please specify

- Grandular Problem YES NO


( diabetes, thyroid) Please specify

-
Disorder of the nervous system YES NO
(migraine, epilepsi, stroke) Please specify

-
Psychiatric or mental health problem YES NO
( depression, nervous breakdown, anorexia) Please specify
-
Eyes, ear, nose, or throat problem YES NO
Please specify

-
Skin problem YES NO
( dermatities, psoriasis) Please specify

-
Have you ever had an operation YES NO
Please specify

-
Have you any allergies YES NO
Please specify

-
Any other accident, illness, injuries recently YES NO

Please specify

I declare that the information I have given is true and complete to the best of my knowledge and I have n withheld
any material facts. I understand that I am responsible for accuracy of my statement and that if
I wilfully suppress any information that I risk the loss of appointment

Signed Date

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