Employee Health Declaration

The purpose of this Health Declaration is to assess what adjustments you may require in order to undertake the position which you have been offered. The information you provide will remain confidential to HR. If the answer to any of the following questions is “Yes” HR may contact, you to discuss this further.

Do you have any health condition that affects you in the following ways or any of the conditions listed below? If so, please give full details including any treatment that you are currently receiving, have recently received, or are waiting to receive.

Affects your physical ability i.e. stamina, walking, balance, bending, kneeling, lifting heavy equipment? *
May impair your consciousness, make you black out, lose concentration or become confused or disorientated? *
Affects your hearing in any way (after correction with any other hearing device)? *
Affects your eyesight in any way (after any lens correction)? *
Causes depression, anxiety, panic attacks, mood swings, anger, other stress-related or emotional issues? *
Causes severe pain? *
Causes excessive drowsiness? *
Any blackouts, fits, epilepsy or faints? *
Any heart problems? *
Any form of diabetes? *
Any asthma or breathing difficulties? *
Any problems with back, legs, arms, neck or joints? *
Any alcohol or drug dependency or misuse? *
Any significant infectious diseases such as tuberculosis or hepatitis? *
Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Gender *
I certify that: *

* Required