Company Forms

Pre-employment Medical Questionnaire

STRICTLY CONFIDENTIAL

According to the information provided on this questionnaire, it will be decided whether or not Two Counties Community Care Limited will request your permission to contact your GP to determine whether any medical conditions are of relevance to the position for which you are applying.

Please complete this form and click SUBMIT to send it to us via the internet. Thank you.

All questions must be answered. Do not leave blank spaces. If in doubt and you wish to consult your GP / Medical Adviser please advise us before completing this form.

Although you should record all health issues, only aspects of health relevant to the job applied for will be taken into account.

If you would prefer to complete and return by post or fax please click here to print a hard copy  ( Adobe PDF )
Post Applied For
SECTION A     -     APPLICANT DETAILS
Title
 Miss Mrs Ms Mr Surname
First Name
                  Email
Retype Email
SECTION B     -     MEDICAL DETAILS
1. How many days have you had sick in the last two years ?   days
2. If you have had any periods of absence from work due to sickness for more than two weeks in the last two years please give details.
3. Are you at present receiving medical treatment / medication ? Yes     No
If Yes, please give details
4. Have you ever been considered medically unfit for any previous employment, life insurance policy, HM Forces or a driving licence? Yes     No
If Yes, please give details
5. Has any abnormality ever been detected as a result of a chest x-ray ? Yes     No
If Yes, please give details
6. Are you at present suffering from, or have suffered in the last five years from, any of the following ?
  Defective vision (not corrected by glasses or contact lenses) Yes     No
  Persistent cough / spitting blood Yes     No
  Bronchitis / Emphysema Yes     No
  Recurring stomach/bowel trouble Yes     No
  Tuberculosis Yes     No
  Recurring bladder trouble Yes     No
  Asthma Yes     No
  Pneumonia / Pleurisy Yes     No
  Fits / blackouts / fainting attacks / Epilepsy Yes     No
  Back strain or trouble/pain Yes     No
  Breathlessness Yes     No
  Hernia rupture Yes     No
  Diabetes Yes     No
  High blood pressure Yes     No
  Anxiety or depression, schizophrenia Yes     No
  Rheumatic fever Yes     No
  Drug/alcohol problems/dependence Yes     No
  Stroke Yes     No
  Ear trouble / deafness Yes     No
  Chest disease / pain Yes     No
  Varicose veins Yes     No
  Serious injury / accident Yes     No
  Severe hay fever or any other allergy Yes     No
  Muscle or joint trouble Yes     No
  Arthritis/knee or hip replacement Yes     No
  Recurring headaches or migraines Yes     No
  Skin trouble/rash/dermatitis/eczema/psoriasis or any other skin condition Yes     No
  Typhoid / Dysentery Yes     No
  Kidney disease Yes     No
  Mental/nervous illness Yes     No
  Stress Yes     No
  Heart disease Yes     No
  Bowel trouble Yes     No
  Serious illness/operation Yes     No
  Head injury / Concussion / Giddiness Yes     No
  Fear of enclosed / open spaces Yes     No
  Thrombosis / leg or foot problem Yes     No
  Colour blindness Yes     No
  Any other significant infection Yes     No
  If you have answered YES to any of the above, please give brief details, including the dates where possible.
 
7. Have you had any periods of continuous illness of two weeks or more during the last five years ? Yes     No
If YES, please give details. How many periods of absence does the total number of days taken cover ?
8. Are you registered disabled or do you have any disability which you consider would impact on the job for which you are applying ? Yes     No
If YES, please give details
9. Please indicate if you have any disabilities which affect:  
  Standing Yes     No
  Manual Handling Yes     No
  Walking Yes     No
  Use of your hands Yes     No
  Bending/stretching Yes     No
  Climbing stairs Yes     No
10. Are you aware of any health problems, symptoms or injuries associated with your current / past job(s) ? Yes     No
If YES, please give details  
11. Have you ever had to change jobs or works assignments because of a health problem or injury? Yes     No
If YES, please give details  
12. Have certain types of work caused you significant strain in your limbs or back ? Yes     No
If YES, please give details  
13. Have you been in hospital during the last 5 years ? Yes     No
If YES, please give details  
14. Have you lived outside of the UK for longer than 6 months within the last 5 years ? Yes     No
If YES, please give details  
15. Do you expect to ask for leave of absence on medical grounds in the near furture ? Yes     No
If YES, please give details  
16. Do you smoke? Yes     No
If YES, please state how many per day
17. Is there any information regarding your health which is not given above but should be taken into account? If none, please write ‘NONE’ Yes     No
If YES, please give details  
SECTION C     -     VACCINATIONS
Have you ever been vaccinated for any of the following: It is advisable for you to ensure that your vaccinations are up to date.
  Yes or No Date
Tuberculosis Yes     No
BCG / Matoux / Heaf / TME Yes     No
Rubella (German Measles) Test Yes     No
Rubella (German Measles) Vaccine Yes     No
Tetanus Yes     No
Polio Yes     No
Hepatitis B Yes     No
SECTION D     -     DECLARATION

I hereby declare that all the above answers are, to the best of my belief, true and complete and I have not withheld any information, which would help in determining my medical fitness for the post for which I am being considered.

I understand that it will be a condition of my employment with Two Counties Community Care Limited that The Commission for Social Care Inspection and any other professional organisations may have access to my personal records at the discretion of the Directors.

I understand that failure to disclose any material information could lead to my appointment being terminated.

If it is necessary to obtain a medical report from your GP or other medical adviser you will be notified by letter. In such cases, your rights under the Access to Medical Reports Act 1988 will be explained to you. The same rights would also apply if, at any time in the employment of TCCC Limited, medical advice were sought about your fitness for work.
Name
Signature (You will be asked to sign this form during your interview)
Date
Thank you for completing this form
  Please remember to also complete and submit the TWO ADDITIONAL FORMS below to apply for a post
Use these documents only to apply online Use these documents only to print out your application
Equal Opportunities Form  ( HTML File ) Equal Opportunities Form  ( Adobe PDF )
Job Application Form ( HTML File ) Job Application Form ( Adobe PDF )
 
   
     
Forms - April 2007
Policy Reference - 2:13:7
Pre-employment Medical Questionnaire and Access to Files
Form 2:10