PRIVATE AND CONFIDENTIAL
HEALTH DECLARATION FORM2
Name: ______________________________________
Date of birth: __________________________
Home Address:___________________________________________________________________________
Telephone no:: _______________________________Mobile no:___________________________________
Doctor’s Name: : _____________________________________
Address: ________________________________________________________________________________
Telephone Number:____________________________________
Occupational Health Department____________________________________________________________
Please answer the following questions by ticking the appropriate boxes. If the answer to any question is Yes,
then please provide full details in the space provided. A Yes answer does not mean you will be discredited for
employment. This will help Veritas 24/7 team to carry out a health and safety risk assessment to ensure that
you are fit for the work or you are given appropriate work and that you get the right support you need.
As an agency worker, it is your responsibility to inform Veritas 24/7 as your employer if any of the following
changes.
Have you ever had in your life, including childhood, any of the following?
Description of Illness
Heart/ Circulation Illness/
Hypertension
Blood Disorders e.g
Anaemia, Haemophilia
Eye Disorder/ Injury or
defect of eye
Asthma, Hay fever
Bronchitis, Pneumonia,
Pleurisy
Tuberculosis
Diabetes
Yes
No
Details/Date
Epilepsy, Frequent fainting
attack
Headaches, Migraines
Psychiatric treatment
Dermatitis, Psoriasis,
Eczema, Skin sensitiveness
Allergy
Chicken Pox (If you suffered
from it in childhood, please
tick)
Hearing Loss, Frequent ear
infections
Hepatitis/ Jaundice
Bladder, Kidney Infections
Gynaecological Problems,
Menstrual pains
Gastric Ailments, Ulcer
Back pain, Sciatica or
Deformities of the spine
Varicose veins
Do you have any deformities
that would affects
movement?
Are you currently receiving
any prescribed medications?
Have you ever been treated
or hospitalize within 12
months?
Are you a Registered
Disabled person?
Have you had recent clinical
investigations? e.g X-ray,
Blood tests?
Do you smoke?
Any other:
Height: ____________________________________
Weight: ___________________________________
Immunisation Status
Have you ever been vaccinated, immunised or tested for any of the following:
Type of Vaccination
Yes
No
Details/ Dates
TB including BCG
Heaf, Mantoux or Tine test?
Rubella (German Measles
Poliomyelitis
Hepatitis B
Hepatitis A antibodies
HIV
Tetanus
Typhoid
Other ( Please provide
details)
DECLARATION
I hereby declare that all the above statement/ information given are true and correct to the best of my
knowledge and belief. I hereby give Veritas Personnel is a specialist healthcare and nursing recruitment Ltd the
permission to contact my General Practitioner to obtain further information should it be required.
Signed by:
Printed Name of Candidate: ______________________________________________
Signature: _____________________________________________
Date: ____________________