Medical Questionnaire
Name *
Your answer
Email *
Your answer
Have you at any time suffered or sustained any major illness or injury? *
If yes, please give details
Your answer
Have you been absent from work for more than three weeks due to illness during the past 3 years? *
If yes, please give the reason/s
Your answer
Do you, or have you ever suffered from any of the following
Depression, anxiety state, nervous illness or breakdown *
Epilepsy or disease of the nervous system *
Bronchitis, asthma or tuberculosis *
Illness relating to kidneys, bladder, liver or glands *
Fainting attacks or dizziness *
Diabetes *
Gastric or duodenal ulcers or indigestion *
Skin disease, boils, dermatitis or eczema *
Back trouble e.g. slipped discs, lumbago, strain or Sciatica *
Heart disease or circulatory problems *
Arthritis, rheumatism *
Have you ever had any hospital investigation or treatment? *
If yes, please specify
Your answer
Have you been vaccinated against
TB *
I declare that the above information are true to the best of my knowledge
Declaration *
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