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Staff Medical Questionnaire

PRIVATE AND CONFIDENTIAL
The purpose of this questionnaire is to alert the College to any issues affecting your health of which the College should be aware, for reasons of ensuring your (or colleagues’) health and safety at work or compliance with any duty of the College to make reasonable adjustments to any provision, criterion, practice or premises that may be required in your case.
Data protection laws require us to give you certain information about how and why we process this information – details can be found in the Privacy Notice on our Policies and Documents page on our website. If you have any questions at all regarding the data protection implications of this questionnaire please speak to the HR Officer.
Please note that not providing this information may prevent us from complying with our duties to you and other colleagues.

Full Name* Please state whether you are suffering or have ever suffered from or had any symptoms of the following complaints:

	Yes	No
Bronchitis, Asthma, Persistent cough, TB, Pleurisy, Infection of the lungs or throat?
Rheumatism, Arthritis, Gout, Rheumatic fever?
Blood Pressure, Palpitations, Shortness of breath, Chest pains, Infection of the heart?
Fits, Fainting, Blackouts, Any disease of the nervous system?
Chronic or persistent indigestion, Gastric or duodenal ulcer, Any other infection of the abdominal organs?
Any infection of the liver, Prostate, Kidneys, Urinary system, Reproductive system?
Enlarged glands, Tumours?
Mental breakdown, Anxiety, Depression?
Diabetes, Thyroid disease, Any other glandular disturbance?
Any accident, Physical defect, Disc or back trouble, Hernia?
HIV or an HIV-related virus?
Any condition not already mentioned?

If you have answered 'yes' to any of the above, please give full details of dates and level of treatment Please state whether you are suffering or have ever suffered from or had any symptoms of the following complaints

	Yes/No	If yes, please give full details of dates and level of treatment
Do you or have you suffered from dermatitis Skin allergies Other skin diseases (eczema, psoriasis, etc.)?
Have you ever had a surgical operation Any other medical investigations?
Are you allergic to any drugs, Specific substances?

Approximately how many days absence have you had from work, school or university for health reasons during the last 5 years?* Please give details of periods of absence due to sickness of five days or more

Are you currently receiving any medical treatment or taking any medication?*YesNo

Details

Have you ever been refused employment because of your health?*YesNo

Have you ever sustained an industrial injury?*YesNo

If yes please give details GP Name and Address*

Please read carefully before ticking the box*I declare the above answers to be true and correct in every respect and understand that, if I have given false particulars, I may be subject to disciplinary action. I am prepared to undergo a medical examination at the Company’s request if this is required.

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