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Appt Form

Pre-Employment Questionaire

Former Occupation(s)

Please provide some detail concerning previous jobs in which you have worked.

Please answer yes or no to the following questions. If yes please give details.

Do you smoke?
Do you drink alcohol? (One unit of alcohol is equivalent to one half pint of beer, one glass or wine or one measure of spirit.)
Do you exercise or play sport?
Have you ever been treated for or had counselling/therapy for an addictive disorder involving drugs or alcohol?
Have you ever been refused work on health grounds? If yes please give details
Have you ever retired or had to give up work on health grounds?
Have you attended any doctor for any problem in the past 5 years
Are you currently taking medication?
Are you having any symptoms or illness investigated currently?
Have you ever had an illness or disability that may affect you ability to carry out you duties safely and to a high standard?
Have you taken sick leave in the past 3 years?

Have you ever had or do you currently have:

Pulmonary or respiratory problems? e.g. asthma, bronchitis, wheezing, TB, pneumonia
Ear, Nose and throat disorder? e.g. hearing difficulty, difficulty with balance, vertigo, tinnitus, ability to smell, rhinitis, hay fever, voice etc
Heart and circulation problems? e.g. anaemia, blood pressure, angina, heart attack, cold or numbness of hands or feet, varicose veins, etc.
Diabetes or thyroid disorders etc?
Nervous system problems? e.g. epilepsy, fits, faints, blackouts, stroke, headaches, migraine, power loss, numbness, pins and needles etc
Skin disorder? e.g. eczema, dermatitis, psoriasis, rashes etc
Digestive problems? e.g. ulcers, gastritis, irritable bowel, crohn’s disease, ulcerative colitis, pancreatitis, liver disease, gall bladder disease etc
Allergies? e.g. medication, chemicals, irritants, cleaning agents, foods etc
Musculoskeletal disorders e.g. neck, back and joint problems, slipped discs, trapped nerves, scoliosis, torn ligament or cartilage, rheumatism, fibromyalgia etc
Overuse injury? e.g. tendonitis, tennis elbow, golfers elbow, frozen shoulder, repetitive strain injury (RSI), work related upper limb disorder WRULD) etc
Urinary problems? e.g. urinary infections, incontinence, kidney stones, prostatism, prostatitis, etc
Female health problems?
Tumours – benign and malignant
Psychiatric or psychological problems? e.g. anxiety, depression, panic attacks, nervous breakdown, burnout, schizophrenia, eating disorder, anorexia, bulimia etc
Accidents, injuries or illness not already noted?

I am fit for the position I have applied.
I can perform my duties safely and without risk to the health and safety of others.
I can render reliable and productive service for my employer​

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement​ to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

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