Confidential Health Questionaire - Chesterfield
OCCUPATIONAL HEALTH DEPARTMENT
CONFIDENTIAL HEALTH QUESTIONNAIRE
Work Experience / Placement
THIS SECTION FOR OFFICE USE ONLY
Full name: …Michelle Day……… …… Post: ………PA…………………………………
Department: ………Education……………………… Extension: ……3738…………………….….
Signature: ……………………………………………… Date handed to applicant: …………………..….
Area of work experience / placement: ………………………………………………………………………..
Dates of attendance, From: …………………….. To: …………………….. Day(s): ……………………..
Hours: ……………………………………………...
THIS SECTION TO BE COMPLETED BY THE APPLICANT IN PRINT
Surname: ……………………………………………… Forename(s): ……………………………………
Title (please circle): Dr / Mr / Mrs / Miss / Ms Date of birth: ……………………………………..
Address: ………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………..
……………………… Postcode: ……………………. Telephone: ……………………………………….
Do you have or have you ever had any of the following:
Yes / No
1. Any serious infectious diseases?
2. Stomach, bowel problems, infections or food poisoning?
3. Asthma, tuberculosis or other chest problems?
4. Any allergy (including hay fever)?
5. Fainting, blackout(s) or epilepsy?
6. Any vision problem(s) not corrected by glasses?
7. Ear problems, infections or hearing defect?
8. Dermatitis, eczema or any skin problems?
9. Joint or back problems?
10. Any disability?
11. Depression / nervous / mental illness or anorexia / eating disorders?
12. Are you diabetic?
13. Are you taking any medicines or tablets?
14. Any other health problem?
If you answered ‘YES’ to any of the above, please give full details (including names of any
medication) on a separate piece of paper and attach it to this application.
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