Health Declaration Form

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Health Declaration Form

Elite Caring Nursing Agency Unit 10 Monaghan Court Business Park, Monaghan Street, Newry, County Down BT35 6BH

Health Declaration Form

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 Problems with limbs which affect movement Severe or frequent headaches or migraines Any type of allergies High Blood Pressure

YES NO DETAILS

Epilepsy, black outs or dizziness Heart illness Bronchitis, asthma or other chest illness Any skin problems

YES NO DETAILS

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?

COMMENTS COMMENTS Have you ever had any of the following diseases? YES NO

Tuberculosis (TB) Mumps Rubella (German Measles) Chicken Pox Shingles Hepatitis / B Typhoid Dysentery Food Poisoning

DETAILS IMMUNISATIONS insert dates obtained where relevant

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:__________________________________________ 3

Please place surgery stamp above

Issued June 2014 Review 2015

Elite Caring Nursing Agency Unit 10 Monaghan Court Business Park, Monaghan Street, Newry, County Down BT35 6BH

Health Certificate

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 4 N031 Issued June 2014 Review 2015

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