Pre Employment Health Questionnaire
A pre employment health questionnaire is used to determine the relative fitness and health of a prospective employee. It is carried out by a health professional and all information given remains confidential. The recruitment process has become tough because of the many regulations but it enables a company to hire the best person for the job. In the search for the best and most suitable employees a company needs to carry out a health and fitness check on all prospective employees. However the information obtained should not be used to discriminate. In most cases it is used for insurance purposes. Below is a sample pre employment health questionnaire.
Insurance policy number: ______________________________
Position applying for: _________________________________
Department of post: __________________________________
Date of application: __________________________________
Company name: _____________________________________
Please indicate whether you have ever or do suffer from the following medical conditions:
Answer with a YES or NO and where necessary you can make a short comment.
Epilepsy _________ ________ ______________________________
Asthma _________ ________ _______________________________
High blood pressure _________ ________ ______________________
Diabetes _________ ________ _________________
Stroke _________ ________ __________________
Heart attack _________ ________ _______________
Allergies _________ ________ __________________
Kidney problems _________ ________ ____________
Back pains _________ ________ _________________
Depression _________ ________ _________________
Other (specify) _________ ________ _______________
Do you suffer from a disability: Yes_____ No: _____ Specify: ________________
Do you receive any disability benefits: Yes: _____ No: _____ Specify: __________
Have you ever had an operation: Yes: _____ No: _____ Specify: ______________
Signature: ____________________________ Date: _________________________
By signing you declare that all the information is truthful.
Category: Employment Questionnaire
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