MEDICAL QUESTIONNAIRE

Thank you for completing your pre-deployment details. Please complete our Medical Questionnaire below.

The information you provide in this medical questionnaire will be handled and processed in accordance with the UK General Data Protection Regulations (UK GDPR) to establish and support fitness required to fulfil this role, and to comply with health and safety obligations.

Information about an individual’s health falls into the special categories of personal data under the UK GDPR. Please see our data protection policy to see how we comply with the principles of UK GDPR in relation to special category data and the processing, retention and erasure of your personal data.

This medical questionnaire will be made available to all authorised personnel involved in the recruitment and selection process.

Your consent is required before this processing can take place.

I consent to the processing of the information I provide in this questionnaire, as stated above.*

Your details

First Name*

Surname*

Email Address*

Gender*

Male

Female

Medical Questionnaire

Have you been absent from work or education in the last two (2) years due to sickness?*

If yes, please state the total number of days.

Yes

Additional Information

Do you have any difficulty in standing, breathing, lifting, or any other movements?*

If yes, please give detail.

Yes

Additional Information

Have you ever had any problems with your joints, including pain, swelling, stiffness?*

If yes, please give detail.

Yes

Additional Information

Do you have any vision or hearing problems?*

If yes, please give detail.

Yes

Additional Information

Do you have any breathing difficulties, for example: Asthma, Bronchitis, Tuberculosis, or other chest difficulties?*

If yes, please give detail.

Yes

Additional Information

Have you ever had any mental illness or psychological problems including depression, anxiety, schizophrenia etc.?*

If yes, please give detail.

Yes

Additional Information

Have you ever suffered from seizures, epilepsy, blackouts, sudden unexplained dizziness, or loss of consciousness?*

If yes, please state the total number of days.

Yes

Additional Information

Have you ever suffered from recurring headaches/migraines?*

If yes, please give detail.

Yes

Additional Information

Do you consider yourself to have a disability?*

If yes, and you feel you need any adjustments or modifications to perform the job, please give details below.

Yes

Additional Information

Do you consider yourself to have a learning disability?*

If yes, please let us know how we can best support you in your role.

Yes

Additional Information

Are you waiting for any treatment or investigations for any health problems?*

If yes, please give detail.

Yes

Additional Information

Are you currently taking any prescription medication?*

If yes, please provide details below.

Yes

Additional Information

Do you give consent for this information to be shared with other colleagues who may need to be informed?*

Yes

Comments

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