RIVERSIDE GROUP (LONDON) Ltd
Medical Questionnaire
Name: _______________________________
Please complete the following form to confirm your current & past medical history. We ask you to complete
this for your own safety and that of others who you may be working with. Please be as honest as you can. The
information that you provide to us is private and confidential.
How would you describe your current state of health? (Delete as appropriate)
POOR / AVERAGE / GOOD / EXCELLENT
 Are you currently suffering from any medical condition that prevents you from undertaking any type
of employment? If yes, please specify.
 Are you currently on any medication? If yes, what for?
 How many days off sick have you had in the last year?
 Have you had an operation? If yes, what for?
 If you answered yes to number 5, have you made a full recovery or does it still affect you?
 Are you currently or have you ever been registered disabled?













Please put tick next any of the following that you have ever suffered from or are currently affected by.
Allergies
Asthma
Back Trouble
Bowel Trouble
Diabetes
Chest Trouble
Dysentery
Ear Trouble
Epilepsy
Eye Trouble
Fainting or blackouts
Hay fever












Heart Trouble
Hepatitis B
High Blood Pressure
Recurring Head Aches
Mental Illness
Salmonella
Skin Trouble
Stomach Trouble
Tuberculosis
Typhoid Fever
Varicose Veins
Fear Of Heights
Thank you for taking the time to complete the above questions. Please sign below to confirm that all
information that you have given above is correct. Should Riverside Group ( London ) Ltd feel the need to clarify
any information that you have given; your signature at the bottom of this page is your authorisation for us to
do so with your GP. We will approach you for these details when required.
Signature: _______________________
Date: ___________________________