Pre-Placement Screening

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The Occupational Health Team Ltd

Full Name *

Date of Birth *

YYYY

Telephone Number *

Email Address *

GP Name & Surgery Address *

Employing Company Name *

Job Applied for *

Hours per week *

Employment History 1 - Name of Previous Employer, Job Role, Dates Employed & Any Hazards in Role. E.g. Noise, Skin or Lung Irritants *

Employment History 2 - Name of Previous Employer, Job Role, Dates Employed & Any Hazards in Role. E.g. Noise, Skin or Lung Irritants *

Employment History 3 - Name of Previous Employer, Job Role, Dates Employed & Any Hazards in Role. E.g. Noise, Skin or Lung Irritants *

How many days have you been absent from work or full-time study during the last two years? *

Have you ever left, or been denied a job for health reasons? *

Yes

Required

Have you attended your G.P in the last two years? *

Yes

Required

Do you suffer from any health problems which may prevent you from undertaking shift work? *

Yes

Required

Have you ever suffered with any of the following? *

Fits / epilepsy / blackouts / unsteadiness?

Frequent headaches / migraine?

Heart problems including angina or high blood pressure?

Respiratory or lung condition such as Asthma?

Hayfever or allergy?

Skin condition/eczema/dermatitis?

Any condition of the bones/joints or limbs i.e back pain, neck pain?

Mental illness/depression or anxiety?

Hearing deficiency/condition of the ear, nose or throat?

Eye disorder/Colour blindness?

Any bowel or stomach disorder?

Are you aware of any other medical problems or complaints?

Are you taking any medication?

Are you receiving medical treatment or investigation?

Do you consider yourself to have a disability?

Any history of drug or alcohol misuse/dependence?

Required

DECLARATION BY APPLICANT:

In signing this questionnaire, you confirm that all information provided by you is true to the best of your knowledge. You also accept that if it is subsequently shown that relevant medical information has not been disclosed by you, or has been misleading or false, then you could become liable to disciplinary proceedings by your employer which may include dismissal.

I understand that I may be required to undergo an examination by an occupational health advisor / physician.

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Date of Completion *

YYYY

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