Employee Health Questionnaire


The main purpose of employee health questionnaires is to establish the health conditions of employees in relation to their ability to effectively carry out their duties and responsibilities. The health assessments that are undertaken through the health questionnaire are typically overseen by a qualified medical practitioner. The information is confidential.

Sample Employee Health Questionnaire

Please complete this form. All information is confidential.

Name …………………………………………………..

Title ………………………………………………………….

Age ………………………………………………………

Address ………………………………………………………

Telephone Number ……………………………………….

Occupation ……………………………………………..

Department ………………………………………….

Please tick against the health conditions that you may have.

* Diabetes

* Epilepsy

* Cardiovascular disease

* Mental condition

* Alcoholism

* Drug dependency

* Allergies (please specify)

* Physical impairment (please specify)

Answer Yes or No to the following questions

Are you currently on any form of prescribed medication?  ___

If yes, please name the medication and what it has been prescribed for………………………………………..

Have you ever undergone a surgical procedure? ___

If yes, please indicate what the procedure was ……………………………………

Have you ever faced occupational challenges as a result of a health condition?  ___

Explain if yes ………………………………………………………………………………………………………………………………

Is there any heath condition that affects your ability to work?

……………………………………………………………………………………………………………………………….

Do you have any difficulty hearing?

………………………………………………………………………………………………………………………………

Has any health problem caused you to be absent from work?………………………………………………………………………..

I hereby declare that the information I have provided in this questionnaire is true.

I understand that any omission/misrepresentation of facts can adversely affect my job and lead to my dismissal from this organization.

Employee’s Signature …………………………………….

Date …………………………………………………………………….

 

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Health Assessments

Category: Employment Questionnaire

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