HEALTH QUESTIONNAIRE
All Trusts and hospitals will require a health statement from you. THE INFORMATION
GIVEN IS CONFIDENTIAL AND WILL ONLY BE USED IN CONNECTION WITH
YOUR POTENTIAL EMPLOYMENT THROUGH CAPITAL CARE SERVICES. The
information is assessed by our Occupational Health Department and sent to hospitals.
Please ensure it is completed fully.
NHS SCREENING
Name of Trust or Hospital which gave you your most recent screening
Date of most recent screening
Were the results in any way abnormal?
YES 
NO 
(If the results were abnormal, please provide details)
MEDICAL HISTORY
If your answer to any of these questions is YES, please give details below.
Is there any aspect of your health that may restrict your ability to
work as a doctor?
YES NO
Are you currently or regularly taking any medicines, tablets,
special diets or injections?
YES NO
Is there any aspect of your medical history about which an
employer should or might wish to know?
YES NO
Have you ever suffered from any mental illness/depression or
alcoholism or drug dependency?
YES NO
Are you attending any hospital for treatment or are you on a
waiting list for any hospital treatment?
YES NO
Do you consume alcohol?
YES NO
If yes, Units __________ / Week.
Do you smoke?
YES NO
If yes, how many per day ______.
Height (cm) _________
Weight ( kg ) ________
Do you now or have you ever suffered from or received treatment for:
a) Respiratory (including asthmatic or allergic) symptoms, disorders or diseases?
YES NO
b) Cardiovascular symptoms, disorders or diseases?
YES NO
c) Gastrointestinal symptoms, disorders or diseases?
YES NO
d) Neurological (including epileptic) symptoms, disorders or diseases?
YES NO
e) Psychiatric symptoms, disorders or diseases?
YES NO
f) Genitourinary symptoms, disorders or diseases?
YES NO
g) Skin symptoms, disorders or diseases?
YES NO
h) Endocrine (including diabetic) symptoms, disorders or diseases? YES NO
i) Haematological symptoms, disorders or diseases?
YES NO
j) Recurrent sore throat or any ENT problems?
YES NO
k) Bone or joint symptoms, disorders or diseases?
YES NO
l) Musculoskeletal problems
YES NO
m) Eating disorders i.e. anorexia or bulimia nervosa
YES NO
n) Immuno-deficiency symptoms, disorders or diseases?
YES NO
o) Stress related symptoms, disorders or diseases?
YES NO
p) Alcohol/drug related symptoms, disorders or diseases?
YES NO
Selby Centre, Selby Road, London N17 8JL Tel: +44 (0) 20 8801 2929 Fax: +44 (0) 20 8880 3470
Web: www.capitalcareservices.com E-mail: info@capitalcareservices.com
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q)
r)
s)
t)
u)
v)
w)
x)
y)
z)
Overseas travel related symptoms, disorders or diseases?
Gynaecological problems
Liver/Gallbladder problems including hepatitis
Oncology problems
Allergies
Disease of the eye, injury to the eye, or defect of vision not
corrected by glasses
How much days off sick have you been in the last two years
(Please give reasons) ………………………………………….
Are you suffering with any of the following: weight loss,
night sweats, coughing, lethargy
Have you recently been in contact with a person who has
pulmonary TB
Have you ever been retired on health grounds
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES NO
YES NO
YES NO
YES NO
YES NO
Please provide any relevant additional information.
LAST CHEST X-RAY
Date
Place
Result
MANUAL HANDLING COURSE
Have you had instruction in lifting techniques when handling heavy loads or patients?
YES NO
IMMUNISATION HISTORY
Have you ever had any of the following immunisations or tests?
Please indicate YES or NO and provide an Occupational Health/GP Immunisation
Report.
Date
Test Result
(Tick if
immunised
in UK)
Rubella (German Measles)*
BCG (TB vaccination)*
Varicella (Chicken Pox)*
MMR
Diphtheria
Poliomyelitis
Tetanus
Measles*
TB Test Heaf/Mantoux*
Evidence of BCG Scar seen by
Occupational health physician
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES









NO
NO
NO
NO
NO
NO
NO
NO
NO
signature
* Please include written/pathological evidence to support your immunity.
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
HEPATITIS B
Please provide a copy of the most recent UK Pathology report showing titre levels.
Hepatitis B antibody titre level and surface antigen.
Hepatitis C Status
IONISING RADIATION CERTIFICATE
Do you hold a POPUMET ionising radiation certificate? YES NO
When was it granted? Date
Please provide a copy of the certificate and evidence of the Core of Knowledge including
authorisation from a Head of Department if not included on the certificate.
DECLARATION
I confirm I have read this document fully and that all the information given to Capital Care
Services UK Ltd is correct. I will notify Capital Care Services UK Ltd should any of the
information alter. I understand and agree to the Terms of Engagement as supplied. I
confirm I have answered the questions in the Health Statement fully. I confirm I am aware
of and have received a précis of the GMC’s statement as supplied by Capital Care Services
UK Ltd, with regard to serious communicable diseases and also that I am aware of the need
to protect patients and myself and agree to notify Capital Care Services UK Ltd should my
circumstances alter.
Signing this form gives Capital Care Services UK Ltd Occupational Health
Department authority to obtain further information from your Occupational Health
Department, Specialist or GP if required.
Signed
Date
Print Name
PLEASE ENCLOSE TWO RECENT PASSPORT SIZED PHOTOGRAPHS WITH THIS FORM
WITH YOUR NAME WRITTEN AT THE BACK .
Please ensure you enclose all supporting documentation where necessary.
Approved By _______________________________ Occupational Health Doctor.
Print Name _____________________________ Date _______________________.
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