An employee health questionnaire helps the employer to get an idea about the health conditions of the employee. This document helps the employer to assess whether the employee would be able to carry out his assigned duties effectively.
It also establishes the fact that whether the employee has any health hazards. All the questions answered in the questionnaire are checked by a doctor. The answers are always kept confidential.
Sample Employee Health Questionnaire
Please complete this questionnaire. All the information provided by you will be kept confidential.
Name: _________________
Middle Name: ______________
Surname: __________________
Designation: _________________
Date of Birth: _________________
Address: ____________________
Telephone Number: ______________
Department: ____________________
Please tick on the appropriate option if you have any history of the below mentioned health conditions:
- Cardiovascular Disease: Yes No
- Diabetes: Yes No
- Mental Disability: Yes No
- Alcoholism: Yes No
- Allergies: Yes No
- Physical disability: Yes No
Please answer the questions correctly:
Are you currently on any kind of medication? ___________________________
Did you ever have to undergo surgery? ___________________________
If yes, what kind to surgery was that? _________________________
Is there any health condition that affects your ability to work? ____________________
Do you have any hearing problem? _________________________________
Do you have any eye related problems? _________________________________
Do you wear spectacles? _____________________________________
Is there any family history of spondylitis? _______________________
Is there any family history of heart ailment? ________________________
I hereby declare that all the information provided by me in this questionnaire is true.
I understand that any distortion of fact can result in losing my job and lead to termination from my employment.
Employee’s Signature __________________________
Date _____________________________________
