Forename

Surname

Date of Birth

Address

Mobile Phone Number

Postcode

Home Phone Number

Email

Name and Address of GP

Has your employment ever been terminated on the grounds of ill health? Has your employment ever been terminated on the grounds of ill health? Yes No

Approximately how many days/weeks sickness absence did you have in the last 12 Months?

What is your height in cm:

What is your weight in Kg:

How many units of alcohol do you consume weekly:

Do you smoke? Do you smoke? Yes No

Are you currently taking prescribed medicine: Are you currently taking prescribed medicine: Yes No

Heart Trouble Heart Trouble Yes No

Jaundice/Hepetitus Jaundice/Hepetitus Yes No

Joint Problems Joint Problems Yes No

Diabetes Diabetes Yes No

Headaches/Migranes Headaches/Migranes Yes No

Serious Accident Serious Accident Yes No

High Blood Pressure High Blood Pressure Yes No

Asthma Asthma Yes No

Hernia or Rupture Hernia or Rupture Yes No

Back/Neck Problems Back/Neck Problems Yes No

Fits/Blackouts/Epilepsy Fits/Blackouts/Epilepsy Yes No

Hearing/Sight Problems Hearing/Sight Problems Yes No

Alcohol Problems Alcohol Problems Yes No

Surgical Operations Surgical Operations Yes No

Drug Problems Drug Problems Yes No

Medical History Details If you have answered, “yes” to any questions in section 2 or 3 – please give details and approximate dates where relevant. Also, please provide details of any qualifying disability under the DDA. This information will enable us to identify what, if any, reasonable adjustments can be made to a specific role and ensure our compliance with the DDA Regulations.

Next of Kin Name

Next of Kin Relationship

Next of Kin Phone

Next of Kin Address