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Staff Medical Questionnaire

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.

Please state whether you are suffering or have ever suffered from or had any symptoms of the following complaints:*
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?
Please state whether you are suffering or have ever suffered from or had any symptoms of the following complaints
 Yes/NoIf 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?
Are you currently receiving any medical treatment or taking any medication?*
Have you ever been refused employment because of your health?*
Have you ever sustained an industrial injury?*
Please read carefully before ticking the box*