Better Healthcare Services
Pre Employment Health Assessment
Your answers to this questionnaire will be CONFIDENTIAL to the Better Healthcare Services
occupational health service. Access to information held on this questionnaire will not be given to anyone
else without your written permission.
The purpose of this questionnaire is to assess whether you have any health problems that could affect
your ability to undertake the duties of the post for which you have applied or place you at any risk within
the workplace. Our aim is to promote and maintain the health of all associates of Better Healthcare
Services.
Please complete this form and return it in the enclosed envelope to the Occupational Health Nurse or bring it
with you when you attend. All the information on the form will be treated in strict confidence and will not be
divulged to any third party without written consent.
Section A - Personal Details
Title
Surname
First Name
Date of Birth
Male / Female
Address
Post Code
Telephone Number
(Home)
Mobile
Telephone Number
(Work)
Job Title
Department
GP’s Name and
Address
Previous occupations
with dates if known for
the last ten years
Have you worked in
the NHS in the last 12
months?
Yes
No
Better Healthcare Services
Pre Employment Health Assessment
Section B – Medical History
Have you ever had or do you have now, any of the following?
1
Impairment which may affect your ability to work safely?
2
Eyesight problems not corrected with glasses/contact lenses?
3
Hearing problems not corrected with a hearing aid?
4
Difficulty in standing, bending, lifting or other movements?
5
Any kind of back problem?
6
Have you ever suffered discomfort when using a computer
keyboard?
7
Any mental illness or psychological problems e.g. depression,
nervous breakdowns, eating disorder, substance misuse or other?
8
A drug or alcohol problem?
9
Fits, blackouts or epilepsy?
10
Any allergies?
11
Asthma, bronchitis or chest problems?
12
Treatment for TB?
13
In the last 12 months have you had a cough for more than 3 weeks,
ever coughed up blood or had any unexplained loss of weight or
fever?
14
Diabetes, thyroid or gland problems?
15
Any illness which may have caused or been made worse by your
work?
16
Episodes of chest pain or breathlessness?
17
Suffer from heart disease or high blood pressure?
18
Are you at present taking or receiving any form of medication?
19
Any operations?
20
Been retired on the grounds of ill health?
22
Are you waiting for or receiving treatment for any medical or mental
health
problem
the suffered
moment?with stress associated with work?
Have youat.
ever
23
Have you ever suffered from Stomach, Bowel or intestinal disorders?
24
Have you ever been screened for MRSA?
25
Are you pregnant?
21
Are you currently taking any drugs or medicines prescribed by a
doctor or purchased from a pharmacy? If so please give the name of
26
the drug/medication and daily dosage.
27
Is there any additional relevant information regarding your health not
covered in the above questions?
Yes No
Don't
know
Better Healthcare Services
Pre Employment Health Assessment
Section C – Food Handlers
You have a duty to report to your employer of any changes to your health.
Are you currently suffering from or have you suffered from any of the
illnesses listed below in the past 3 months
I
Diarrhoea
2
Blood Poisoning
3
Skin trouble
4
Ear or eye infection
5
Sore throat
6
Sinusitis
7
Lung disease (eg Bronchitis, TB)
8
Persistent cough
9
Vomiting (as a result of known or suspected food poisoning)
Section D – Sickness Absence
How many days have you lost from work or College during the past 2 years?
What was this due to?
Yes
No
Better Healthcare Services
Pre Employment Health Assessment
Section E – Immunisations
Have you ever had any of the following Vaccinations/Immunisations?
(please obtain as much information from your GP and include copies of certificates and/or lab reports, as
this will speed up the employment process)
Yes No
Don't
Know
Dates
Results
BCG (proof required by
health professional)
Tetanus
Poliomyelitis
Hepatitis A
Hepatitis B: 1,2 &3
Hepatitis B booster
Hepatitis B antibody screen
status (copy of blood test
result required)
Rubella
MMR 1st vaccination
MMR 2nd vaccination
Have you ever had chicken
Pox or shingles?
Chest X Ray (clear?)
Any other Immunisation or
vaccination information?
Copies of certificates/lab reports to be enclosed if possible
Section F – Exposure Prone Procedures
Health care workers who perform Exposure Prone Procedures have a legal duty to inform their
employer if they suspect or know they are carriers of HIV, Hepatitis B or Hepatitis C.
Exposure Prone Procedures are those procedures where the workers gloved hands may be in full contact
with sharp instruments, needle tips or sharp tissue (e.g. spicules of bone or teeth) inside a patient’s open
body cavity, wound or confined anatomical space where the hands or fingertips may not be completely
visible at all times.
Have you ever tested positive for any of the following
Hepatitis B
Yes
No
Hepatitis C
Yes
No
HIV
Yes
No
If you are expected to carry out EPP’s fitness for employment will not be given until Occupational Health
Advisor has seen documentary evidence of Hepatitis B, Hepatitis C and HIV status.
Better Healthcare Services
Pre Employment Health Assessment
Section G
If you have answered ‘yes’ to any of the questions in sections B or C, please give further details below.
Continue on a further sheet if necessary.
Question Number
Details
Section H – Night Workers
The following section is to be completed only by those members of staff who regularly undertake night
duty.
Have you suffered from and been treated for any of the following. If Yes, please give details of the
condition and whether they are ongoing at present.
Yes
Have you worked nights before?
If yes: Did you suffer any health problems directly related to night
work?
If yes: Give details
Heart or circulatory disorders
Stomach, bowel or intestinal disorders
Do you have any medical condition that may affect your ability to work
at night?
No
Better Healthcare Services
Pre Employment Health Assessment
Section I – Declaration
I declare that the information on this form is true to the best of my knowledge. Further, I
understand that if I should be found to knowingly make a false statement regarding my
medical history either in answering the above questions or to the Company’s Director of
Quality and Training, or should I conceal any material fact, the Company can terminate
my contract without notice.
Employee’s Signature
Print Name
Date:
Better Healthcare Services
Pre Employment Health Assessment
For Official Use Only
Results of Health Questionnaire
Name of Candidate
Position
Branch
Date of review of health questionnaire
Outcome of
deferral/referral
Fit
Immunisations Required
Fit with restrictions
Unfit
Fit for EPP
Restrictions
Mantoux test
BCG scar check
Hepatitis B 1,2 &3
Hepatitis B booster
Hepatitis B Antibody screen
Hepatitis A 1 & 2
Varicella
Rubella
No immunisations required.
Signature of Occupational Health
Nurse
Date personnel notified in writing
Date personnel notified by telephone
Date: