Better Healthcare Services

Pre Employment Health Assessment

Your answers to this questionnaire will be CONFIDENTIAL to the Better Healthcare Services
occupational health service. Access to information held on this questionnaire will not be given to anyone
else without your written permission.
The purpose of this questionnaire is to assess whether you have any health problems that could affect
your ability to undertake the duties of the post for which you have applied or place you at any risk within
the workplace. Our aim is to promote and maintain the health of all associates of Better Healthcare
Services.

Please complete this form and return it in the enclosed envelope to the Occupational Health Nurse or bring it
with you when you attend. All the information on the form will be treated in strict confidence and will not be
divulged to any third party without written consent.

Section A - Personal Details

Title       Surname      

First Name      

Date of Birth       Male / Female      

Address      

Telephone Number
Post Code      
(Home)
     

Telephone Number
Mobile      
(Work)
     

Job Title       Department      

GP’s Name and

     
Address

Previous occupations
with dates if known for      
the last ten years

Have you worked in

the NHS in the last 12 Yes No
months?
 Better Healthcare Services
Pre Employment Health Assessment
Section B – Medical History

Don't
Have you ever had or do you have now, any of the following? Yes No
know
1 Impairment which may affect your ability to work safely?
2 Eyesight problems not corrected with glasses/contact lenses?
3 Hearing problems not corrected with a hearing aid?
4 Difficulty in standing, bending, lifting or other movements?
5 Any kind of back problem?
Have you ever suffered discomfort when using a computer
6
keyboard?
Any mental illness or psychological problems e.g. depression,
7
nervous breakdowns, eating disorder, substance misuse or other?
8 A drug or alcohol problem?
9 Fits, blackouts or epilepsy?
10 Any allergies?
11 Asthma, bronchitis or chest problems?
12 Treatment for TB?
In the last 12 months have you had a cough for more than 3 weeks,
13 ever coughed up blood or had any unexplained loss of weight or
fever?
14 Diabetes, thyroid or gland problems?
Any illness which may have caused or been made worse by your
15
work?
16 Episodes of chest pain or breathlessness?
17 Suffer from heart disease or high blood pressure?
18 Are you at present taking or receiving any form of medication?
19 Any operations?
20 Been retired on the grounds of ill health?
Are you waiting for or receiving treatment for any medical or mental
21
health
22 problem
Have youat.ever
the suffered
moment? with stress associated with work?
23 Have you ever suffered from Stomach, Bowel or intestinal disorders?

24 Have you ever been screened for MRSA?

25 Are you pregnant?

Are you currently taking any drugs or medicines prescribed by a
doctor or purchased from a pharmacy? If so please give the name of
26
the drug/medication and daily dosage.

Is there any additional relevant information regarding your health not

27
covered in the above questions?
 Better Healthcare Services
Pre Employment Health Assessment
Section C – Food Handlers

You have a duty to report to your employer of any changes to your health.

Are you currently suffering from or have you suffered from any of the
Yes No
illnesses listed below in the past 3 months
I Diarrhoea
2 Blood Poisoning
3 Skin trouble
4 Ear or eye infection
5 Sore throat
6 Sinusitis
7 Lung disease (eg Bronchitis, TB)
8 Persistent cough
9 Vomiting (as a result of known or suspected food poisoning)

Section D – Sickness Absence

How many days have you lost from work or College during the past 2 years?
What was this due to?
     
 Better Healthcare Services
Pre Employment Health Assessment
Section E – Immunisations
Have you ever had any of the following Vaccinations/Immunisations?
(please obtain as much information from your GP and include copies of certificates and/or lab reports, as
this will speed up the employment process)

Don't
Yes No Dates Results
Know
BCG (proof required by
           
health professional)
Tetanus            
Poliomyelitis            
Hepatitis A            
Hepatitis B: 1,2 &3            
Hepatitis B booster            
Hepatitis B antibody screen
status (copy of blood test            
result required)
Rubella            
MMR 1st vaccination            
nd
MMR 2 vaccination            
Have you ever had chicken
           
Pox or shingles?
Chest X Ray (clear?)            
Any other Immunisation or
     
vaccination information?

Copies of certificates/lab reports to be enclosed if possible

Section F – Exposure Prone Procedures

Health care workers who perform Exposure Prone Procedures have a legal duty to inform their
employer if they suspect or know they are carriers of HIV, Hepatitis B or Hepatitis C.
Exposure Prone Procedures are those procedures where the workers gloved hands may be in full contact
with sharp instruments, needle tips or sharp tissue (e.g. spicules of bone or teeth) inside a patient’s open
body cavity, wound or confined anatomical space where the hands or fingertips may not be completely
visible at all times.

Have you ever tested positive for any of the following

Hepatitis B Yes No
Hepatitis C Yes No
HIV Yes No

If you are expected to carry out EPP’s fitness for employment will not be given until Occupational Health
Advisor has seen documentary evidence of Hepatitis B, Hepatitis C and HIV status.
 Better Healthcare Services
Pre Employment Health Assessment
Section G

If you have answered ‘yes’ to any of the questions in sections B or C, please give further details below.
Continue on a further sheet if necessary.

Question Number Details

           

           

           

           

           

           

           

           

           

Section H – Night Workers

The following section is to be completed only by those members of staff who regularly undertake night
duty.

Have you suffered from and been treated for any of the following. If Yes, please give details of the
condition and whether they are ongoing at present.

Yes No
Have you worked nights before?
If yes: Did you suffer any health problems directly related to night
work?
If yes: Give details
Heart or circulatory disorders
Stomach, bowel or intestinal disorders
Do you have any medical condition that may affect your ability to work
at night?
 Better Healthcare Services
Pre Employment Health Assessment
Section I – Declaration

I declare that the information on this form is true to the best of my

knowledge. Further, I understand that if I should be found to knowingly make
a false statement regarding my medical history either in answering the
above questions or to the Company’s Director of Quality and Training, or
should I conceal any material fact, the Company can terminate my contract
without notice.

Employee’s
      Date:      
Signature

Print Name
 Better Healthcare Services
Pre Employment Health Assessment
For Official Use Only

Results of Health Questionnaire

Name of Candidate      

Position       Branch      

Date of review of health questionnaire      

Outcome of
Fit Fit with restrictions Unfit Fit for EPP
deferral/referral

Immunisations Required Restrictions

Mantoux test      

BCG scar check      

Hepatitis B 1,2 &3      

Hepatitis B booster      

Hepatitis B Antibody screen      

Hepatitis A 1 & 2      

Varicella      

Rubella      

No immunisations required.      

Signature of Occupational Health

      Date:      
Nurse

Date personnel notified in writing      

Date personnel notified by telephone