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Elite Caring
Nursing Agency
Unit 10 Monaghan Court
Business Park, Monaghan Street,
Newry, County Down BT35 6BH
Please complete the Health Declaration Form ensuring each section is fully completed
Have you previously had a pre-employment health assessment?
YES NO (Please circle as applicable)
If YES have you been passed?
YES NO (Please circle as applicable)
If NO, please indicate below
_______________________________________________________________________________________________
___________________________________________
If you have had any previous Health assessments please provide details below:
LOCATION DATE POST
Medical History
Have you seen your GP or Consultant within the past two years?
Are you receiving any type of treatment from your doctor?
Have you ever been admitted to hospital for any reason?
Have you been absent from work within the past two years due to illness?
YES NO DETAILS COMMENTS
N031 Issued June 2014 Review 2015

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Do you suffer from, or have you ever had any of the following?
Back pain or injury
YES NO DETAILS
Problems with limbs which affect movement
Severe or frequent headaches or migraines
Any type of allergies
High Blood Pressure
Epilepsy, black outs or dizziness
Heart illness
YES NO
Bronchitis, asthma or other chest illness
Any skin problems
Nervous disorders
Diabetes
Hearing problems
Eye-sight problems
Have you ever had any industrial or occupational disease?
Have you ever had any work related accidents?
Have you ever been diagnosed with a medical or disability which may effect your ability to carry out your job?
Have you ever had any of the following diseases?
YES NO
DETAILS
DETAILS
COMMENTS
COMMENTS
Tuberculosis (TB)
Mumps
IMMUNISATIONS insert dates obtained where relevant
Rubella (German Measles)
Chicken Pox
Shingles
Hepatitis / B
Typhoid
Dysentery
Food Poisoning
I declare that the information provided is true and complete to the best of my knowledge, and that I have not deliberately withheld any relevant information.
Signed:______________________________________ Date:___________________
N031 Issued June 2014 Review 2015

N031
GP VERIFICATION
I can confirm that the information provided is true and correct to the best of my knowledge.
Signed:________________________________________
Position:_______________________________________
Date:__________________________________________
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Issued June 2014 Review 2015

Elite Caring
Nursing Agency
Unit 10 Monaghan Court
Business Park, Monaghan Street,
Newry, County Down BT35 6BH
Please take the attached Health Questionnaire to your stated GP for completion.
RE:
NAME:
ADDRESS:
POSTCODE:
DATE OF BIRTH:
POSITION APPLIED: AGENCY NURSE
DATE:
Dear Dr …………………
The above candidate has applied for work as an Agency Nurse through our agency.
We would appreciate if you could complete, sign and place a surgery stamp on the attached medical questionnaire.
I appreciate you time in dealing with this matter.
Yours sincerely
_____________________________
Tina Poacher
Recruitment Manager
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N031 Issued June 2014 Review 2015