Strictly Confidential
ID
Ref.
Medical Report
To be completed by all applicants for employment
Please answer all questions, using BLOCK CAPITALS
Ass’t.
OH1a
PRE-PLACEMENT QUESTIONNAIRE
NOTE: To be completed by the applicant
Surname: Mr/Mrs/Miss/Ms
All Forenames:
Address:
Postcode:
Daytime telephone Number:
Date of Birth:
Evening Telephone Number:
Position applied for:
Part time/ full time/ shifts:
Company/Location:
HR Contact:
HEALTH SURVEILLANCE REQUIRED: (To be completed by the appointing manager)
Specific Surveillance required (tick all that apply)
Baseline Surveillance
Audiometry
Lung Function Test
Fork Lift Truck Driver
Skin Checks (COSHH)
Working at Heights assessment
Confined Spaces/Breathing apparatus
Physician only:
PCV/PSV
Blood Lead monitoring
√
Specific Surveillance required (tick all that apply)
Food handlers
Vision screening
Lone Worker
Hand Arm Vibration screening
Driving medical assessment
Night Shift worker
√
Ionising radiation
Asbestos
DATA PROTECTION
CueDoc Occupational Health will use the medical information contained in this document to provide a medical view
of your fitness for employment or specific task. CueDoc Occupational Health will hold this, and any other medical
information which they may obtain about you, under secure conditions throughout your period of employment and
for the statutory time requirements. If you are unsuccessful in obtaining employment with the Company, your
medical information will be destroyed six months from the date on this form.
Under the provisions of the Data Protection Act 1998 you have a right of access to information held about you (with
exceptions). Whilst no medical information will be disclosed without your prior written permission, a report advising
on your fitness for work will be given to management.
I understand the above statement relating to the processing of medical information and I hereby give
consent for details regarding my medical history and examination to be held by CueDoc Occupational
Health.
I further understand that CueDoc Occupational Health may, in appropriate circumstances, discuss the
outcome of any medical examination prior to employment with the Company or disclose any relevant
information in connection with my health and employment. This information will only be shared at senior
level, i.e. Director/Head of Human Resources and I hereby give consent to this.
I understand that this discussion will relate only to matters affecting my fitness or otherwise for the post
applied for.
Signed:
Date:
1
Owner: S Holliday
Version 5
CueDoc Occupational Health
A Trading Name of OH Acquisitions Limited
Registered in England Registered No: 7365943
Issue date: January 2011
Registered Address: Suite 3, Telford House, Riverside, Warwick Road, Carlisle, Cumbria, CA1 2BT
Tel: 01228 513687, Fax No: 01228 319636
www.cuedococcupationalhealth.co.uk
PART I
Medical Questionnaire
To be completed by all applicants for employment.
(Answer Yes or No as applicable)
1. Do you have normal vision with/without glasses or contact lenses?
YES
NO


If answer is NO, please give details below.
2. Have you received any treatment or medication (e.g. repeat prescriptions) from a doctor or


hospital during the last year?
If yes, please give details
________________________________________________________________________________________
________________________________________________________________________________________
3. Have you been absent from work or full time study due to sickness/injury in the last 12 months?




If yes, please give details
4. Do you have any other form of medical condition, impairment or disability that may restrict
your ability to carry out the duties of the role that you have applied for?
If so, please give details (continue on a separate sheet if required)
I
certify that to the best of my knowledge, the information
(FULL NAME IN CAPITALS)
I have given is complete and correct
Applicant’s signature: _____________________________________________ Date: ___________________
For Occupational Health use:
Fit for the proposed job
Fit with restrictions/adjustments:
Details:
Fit Certificate sent to HR: 
Copy filed: 
Invoice: 
Unfit for the proposed job
Further information requested from GP/other health professional
2
Owner: S Holliday
Version 5
CueDoc Occupational Health
A Trading Name of OH Acquisitions Limited
Registered in England Registered No: 7365943
Issue date: January 2011
Registered Address: Suite 3, Telford House, Riverside, Warwick Road, Carlisle, Cumbria, CA1 2BT
Tel: 01228 513687, Fax No: 01228 319636
www.cuedococcupationalhealth.co.uk