Please find below your Health Declaration Questionnaire Information for you to complete.
Health declaration questionnaire information
Thank you for accepting a place on a pre-registration healthcare course at The University of
Northampton.
Following the publication of the Clothier Report recommendations, all applicants for preregistration healthcare courses need to undertake occupational health screening. You
therefore need to do the following now:1.
Complete the Health Declaration Questionnaire on pages 2-5.
2.
Take the GP Health questionnaire on page 6 to your GP for completion. This should
then be returned to you. (You will be required to meet any cost incurred).
3.
Send both the completed Health Declaration Questionnaire and the GP Health
Questionnaire to the Occupational Health Department at Northampton General
Hospital unless you are coming to do Nursing or Midwifery, in which case you must
return both questionnaires to your host site. All addresses can be found on page 7.
4.
You must then contact the relevant Occupational Health Department to arrange an
appointment five working days after you have posted your questionnaire. It is your
responsibility to contact the relevant Occupational Health Department to arrange an
appointment, they will not contact you.
Occupational Health Departments:
All students on Dental Nursing, Health and Social Care, Occupational Therapy, Paramedic
Science and Podiatry must contact Northampton General Hospital where they will attend for
screening. Students studying Nursing or Midwifery will be allocated a Host Site of
Northampton, Kettering or Milton Keynes, and therefore must contact their allocated
department to arrange their appointment. Host sites will be allocated by mid/end June.
Northampton General Hospital NHS Trust 01604 545558/544616
Kettering General Hospital NHS Trust
01536 492234
Milton Keynes Hospital NHS Trust
01908 243609
If you require any further information or advice, please contact Admissions on 01604
892635 or 01604 892588.
(Revised April 2007)
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Health declaration questionnaire
Personal details (Please use block capitals)
COURSE APPLIED FOR
PATHWAY
_________
YEAR OF ENTRY ___________
SURNAME
MR/MRS/MISS/MS/DR
FIRST NAME(S)
DATE OF BIRTH
PREVIOUS / MAIDEN NAME(S)
______________
National Insurance No
ADDRESS
___POST CODE_____
TEL NO - HOME
MOBILE_______________
DOCTOR’S NAME
ADDRESS
TEL NO
_____
___________
POST CODE_________________
To all Applicants
Your appointment is subject to satisfactory health clearance, which requires you to
complete this form now and return it to the relevant Occupational Health Department. It
is important that you do this as soon as possible.
Information given to us about your health will be treated in the strictest confidence.
Your answers to this questionnaire will help us to ensure that the work you are planning
to do will not place your health at risk and will be used to establish that you, in turn, do
not provide a health risk to patients or other staff.
You are required to declare at the end of the questionnaire that all your answers are
correct to the best of your knowledge. You should be aware that if you leave anything
out intentionally or answer untruthfully, your appointment might be affected.
You will be required to attend a clinical assessment in Occupational Health and should
therefore contact the relevant Occupational Health Department. With your permission
we may also contact your GP or hospital specialist.
Previous employment details
Please list your employment details for the past 10 years starting with your present
employment.
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Dates: From
To
Specific Workplace
Hazards
Employer/Dept/Unit
Your health details - confidential
Height
Weight
______st/ lbs or Kgs
Alcohol – Units per week ______
 During the past two years how many occasions have you taken sick leave from work or
training / education? _________
 Approximately how many days in total does this amount to?
Have you ever had
YES
NO
days
If YES please give brief details including
dates (continue on a separate sheet if
required)
Have you ever had a work-related
injury and/or disease?
Do you have a disability, which may
require adaptation of work place or
work schedule?
Have you previously left a job /
training on grounds of ill health?
Have you had any major accidents?
Have you ever been admitted to a
hospital of any kind for treatment?
Have you ever attended an outpatient clinic?
Have you attended a casualty
department in the last five years?
If ‘Yes’ how many times and for what
reason.
Do you regularly need to consult
your General Practitioner?
If ‘Yes’ with what conditions /
problems.
Are you presently on any
medication? If so what?
Have you lived or worked abroad
during the past five years?
Have you ever been found to be
unsuitable for healthcare work?
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Have you ever had
YES
NO
If YES please give brief details
including dates (continue on a
separate sheet if required)
A mental health condition, e.g. anxiety,
eating disorder, mood disorder,
depression, hypomania, suicide attempts,
Any
historyschizophrenia?
of stress and/or counselling?
self harm,
Consultation and/or treatment in a
Mental Health Clinic or had counselling?
Drugs or alcohol dependence?
Epilepsy, fits blackouts, fainting attacks,
or recurrent dizziness?
Heart problems or high blood pressure?
Kidney or bladder problems?
Gastric / duodenal ulcer or bowel
problems?
Persistent / recurrent attacks of
diarrhoea / vomiting / abdominal pain?
Recent unexplained weight loss?
Jaundice or hepatitis?
Hernia or varicose veins?
Persistent / recurrent backache, sciatica,
disc or other back problems?
Problems with your neck, shoulders,
arms, hands / wrists?
Other joint problems such as arthritis or
rheumatism?
Deformities or problems affecting
movements?
Tuberculosis (TB), recurrent cough, blood
stained sputum, night sweats,
unexplained
weight
loss? difficulties,
Chest problems,
breathing
wheezing or recurrent bronchitis?
Asthma, hay fever or allergy to anything?
(e.g. Latex)
Migraine / persistent headaches?
Persistent ear problems or hearing
defect?
Eye problems or vision defect?
Diabetes, thyroid or gland problems?
Any other significant health problems /
operations not mentioned above?
Have you ever been in positive contact
with MRSA (Methicillin Resistant
Staphylococcus Aureus) in the last six
months or ever been positive?
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Do you need any extra facilities and/or
support to attend the Occupational
Health department for further
assessments?
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Not confidential – immunisations and infection diseases
The following information may be passed on to other Occupational Health Departments
and / or your manager for infection control purpose to protect you and your patients
Have you ever had chicken pox or shingles?
YES / NO
Have you had Varicella blood test? If YES please give result:
Immune / Non immune
Have you been in contact with anyone suffering with TB in the past three years? YES /
NO
If YES give details.
If in doubt about dates, please check with your GP and / or Occupational Health Service.
Scar present

Yes 
TB – BCG
Date
Heaf or Mantoux test (most recent)
Rubella Immunisation (German
Measles)
MMR (Measles Mumps & Rubella)
Date
Date
Result
Blood Screening
Date
Date
Polio - primary course
Date
Last Booster
Date
Tetanus - primary course
Date
Last Booster
Date
Pol/Dip/Tet (Polio, Diphtheria &
Tetanus)
Hepatitis A - primary course
Date
Last Booster
Date
Date
Last Booster
Date
Hepatitis B - Full course completed
Date
Last Booster
Date
Date
Result:
Hepatitis C Antibody Test
Date
Result : Positive / Negative
Varicella Vaccine
Dates 1st
Date 2nd
Meningitis C
Date
Date
- Last Blood test
Date
Result
Declaration
I certify that the answers to the aforementioned questions are correct to the best of my
knowledge. I give consent to be examined if necessary*. I am aware that failure to
make a full declaration of health may lead to dismissal. I understand that no medical
details will be divulged without my permission to any person outside the Occupational
Health Service, but an opinion about my fitness for work will be given to the admissions
officer.
*Please note midwifery and paramedic students will always need to be seen by
Occupational Health to confirm fitness prior to commencement of course. This is a
requirement from the Department of Health with regard to screening for blood borne
viruses.
SIGNED
_____
____
DATE_____
For occupational health use only
For Health Interview with OH Nurse Adviser 
GP Health Questionnaire received YES / NO
Medical with OH Physician 
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No
Fit for Post

Documented evidence of Hepatitis B immunity required 
Documented evidence of Hepatitis B immunity supplied 
SIGNED
DATE
GP Health Questionnaire for Prospective
Pre-registration Healthcare Students
Dear Doctor
The person who has brought you this letter has accepted a place on a pre-registration
healthcare course in the School of Health at The University of Northampton.
Following the publication of the Clothier Report recommendations, applicants for preregistration healthcare training are required to provide a report from their general
medical practitioner before an appointment can be considered. I should be most
grateful, therefore, if you would complete the questionnaire below and return it to the
applicant, who will be required to meet any cost incurred.
Thank you for your co-operation.
Admissions
The University of Northampton
Name of Applicant
Does the above person suffer or have ever suffered from:
Psychological/psychiatric symptoms
An eating disorder including anorexia or bulimia nervosa
Alcohol or drug problems
YES/NO
YES/NO
YES/NO
Is there a history of frequent attendance at GP surgery or A & E Dept
Deliberate self harm
Personality disorder
YES/NO
YES/NO
YES/NO
What, if any, treatment is currently being given?
Signature of GP: -------------------------------------------- Date: ------------------Address--------------------------------------------- GP Stamp
------------------------------------------------------
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I, the undersigned, agree for this information to be provided by my GP to the relevant
Occupational Health Department as a requirement of my application for pre-registration
healthcare training.
Signed………………………………….. Print Name……..…………………………. Date………………….
(Revised October 2006)
Host site addresses
Nursing and Midwifery students:
You should return your forms to the Occupational Health Department at your host site
and mark the envelope as confidential.
Occupational Health Department
Warren Hill House
Kettering General Hospital NHS Trust
Rothwell Road
Kettering
NN16 8UZ
Occupational Health Department
Acorn Centre
Milton Keynes General Hospital NHS Trust
Standing Way
Eaglestone
Milton Keynes
MK6 5LD
Occupational Health Department
Northampton General Hospital NHS Trust
Billing House
Cliftonville
Northampton
NN1 5BD
All other students:
Send both the above questionnaires to the Occupational Health Department at
Northampton General Hospital at the address above marking the envelope as
confidential.
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