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HEALTH QUESTIONNAIRE
Name (please print):
Doctor’s Name and Address:
Have you, within the last three years, had any illness or accident causing you to be off work for two weeks or more? YES / NO
If YES, what was the illness or accident?
Have you, within the last three years, attended an outpatient’s clinic or had a course of treatment (tablets, injections,
physiotherapy) lasting one month or more? YES / NO
Are you now receiving such treatment? YES / NO
If YES, please give details.
I certify that the information on this form is correct and understand that any mis-statement or suppression of information will be
viewed as misconduct and will be subject to the Company’s Disciplinary Procedure.