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.

Name: _____________________________________________

Address: ___________________________________________

Telephone: _________________________________________

Mobile: ____________________________________________

Email: _____________________________________________

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.

Medical condition

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.