Health Questionnaire

Health Questionnaire
This information is private and confidential. If we have any concerns about your fitness for work employment will be subject to satisfactory medical reports.
Name:*
Prefix First Last
Have you ever had:
Tuberculosis, asthma, bronchitis or chest problems?*
If Yes, Please provide more information:*
Chest pain, heart condition or raised blood pressure?*
If Yes, Please provide more information:*
Blackouts, fits or attacks of giddiness?*
If Yes, Please provide more information:*
Depression, mental illness or nervous breakdown?*
If Yes, Please provide more information:*
Rheumatism or arthritis?*
If Yes, Please provide more information:*
Back trouble?*
If Yes, Please provide more information:*
Diabetes, thyroid or other gland trouble?*
Dermatitis or skin trouble?*
Any other accident, operation or illness?*
If Yes, Please provide more information:*
Have you any reason to believe you may be infected with any communicable disease?*
Any other current or recent medical condition or treatment which might affect your attendance or performance at work?*
If Yes, Please provide more information:*
Do you intend to work night duties on a regular basis?*
Any illness or medical condition that prevented you from attending work on your normal duties or activities for more than one week during the past year?*
If Yes, Please provide more information:
Any physical or mental impairment, which has a substantial and long term effect on your ability to carry out day to day activities?*
If yes, please specify and special adjustments required in relation to work.*
Do you smoke?*
How many units of alcohol do you drink per week?
(one unit = 1⁄2 pint beer = 1 glass wine = 1 single whisky)
Privacy Policy*
- I give consent to Rosa Clean LTD to use my personal information for the purposes of my contract of Employment. I also understand information I have given will be used to carry out reference checks.
Data Withdrawal*
- I understand that if in future I would like to withdraw my details from the system I must return to this website and access the - Data Withdrawal Form.

Save and Continue Later

Have you ever had: