Health Declaration Office Staff Questionnaire
Health Declaration Office Questionnaire V2
Please complete the following questions. The information will remain confidential to the Occupational Health service and will not be divulged to any other person without your consent.
Full Name
*
Date of Birth
*
Address - First Line
*
Address - Town
*
Address - County:
*
Address - Post Code:
*
Telephone No
*
Physical gender at birth
*
Male
Female
Company Name:
*
Job Title/Position:
*
Please answer each question below and provide details if necessary
Do you have any disability, chronic health condition or are Neurodivergent?
*
Yes
No
If yes, please provide details
*
Any health problems that may have been caused or made worse by any previous work?
*
Yes
No
If yes, please provide details
*
Do you need any special aids /adaptations to assist you at work, whether or not you have a disability?
*
Yes
No
If yes, please provide details
*
Do you suffer from or have you ever suffered I experienced any of the following?
A Heart Attack?
*
Yes
No
If yes, please provide details (including date)
*
Angina?
*
Yes
No
If yes, please provide details
*
Swelling of a major artery(aneurysm) inside your chest or abdomen?
*
Yes
No
If yes, please provide details
*
An operation on your heart/stent insertion?
*
Yes
No
If yes, please provide details
*
Asthma, bronchitis or any other chest disease?
*
Yes
No
If yes, please provide details
*
High Blood pressure?
*
Yes
No
If yes, please provide details
*
Diabetes? Type1/Type 2
*
Yes
No
If yes, please provide details
*
A fit or Epileptic seizure?
*
Yes
No
If yes, please provide details
*
Partial loss of consciousness, a blackout or faint?
*
Yes
No
If yes, please provide details
*
Dizzy spells, Vertigo or a spinning feeling in the head?
*
Yes
No
If yes, please provide details
*
An operation on your brain/brain tumour/bleed on the brain?
*
Yes
No
If yes, please provide details
*
A stroke or Transient Ischaemic Attack (TIA)?
*
Yes
No
If yes, please provide details
*
A head injury requiring admission to hospital?
*
Yes
No
If yes, please provide details
*
Do you have eye disease, double vision or wear glasses/lenses?
*
Yes
No
If yes, please provide details
*
Do you have any hearing issues/use hearing aids?
*
Yes
No
If yes, please provide details
*
Have you ever had Cancer/Malignant Growth/ Tumour?
*
Yes
No
If yes, please provide details
*
Joint problems/Pain/Swelling in joints/Mobility issues?
*
Yes
No
If yes, please provide details
*
Do you have thyroid problems, over or underactive
*
Yes
No
If yes, please provide details
*
DECLARATION
I certify that the answers to the above questions are correct to the best of my knowledge. I understand that no medical details will be divulged without my consent to any person outside of the Occupational Health Service, but an opinion about my fitness to work will be given to Management.
Enter your full name to confirm the above information
*
Submit
