Pre Employment Medical Questionnaire


During the recruitment process most companies require to find out the medical history of all prospective employees.  They do not use this information to discriminate.  All information needs to be honest and accurate.  In your search for employment you will find it routine to fill out a pre employment medical questionnaire.  The questions are simple and easy to answer and your information remains confidential.  You should not miss out on job opportunities by not filling out this questionnaire as it is a very important part of the recruitment process.  You need to be truthful and candid in all the questions.

Name: _____________________________________

Address: ___________________________________

Tel: _______________________________________

Mobile: ____________________________________

Email: _____________________________________

Date of birth: ________________________________

Insurance policy number: ______________________

Post applied for: _____________________________

Your height: ________________________________

Your weight: ________________________________

Please answer the following questions with a yes or no where applicable:

Do you smoke? _______________________________

Do you drink alcohol? __________________________

Are you under any medication? ___________________

Are you under any medical supervision? ____________

Have you ever suffered from an ailment that resulted in an absence from work? ________

If so please specify: _______________________________________________________

________________________________________________________________________

Please indicate the total number of sick days you took out in the past year: ____________

Have you ever been admitted in hospital? ______________________________________

If so please specify: _______________________________________________________

________________________________________________________________________

Do you suffer from any medical condition that could hamper your sight, hearing, coordination or other sensory ability? _________________________________________

If so please specify: _______________________________________________________

________________________________________________________________________

Signature: ____________________________            Date: _________________________

By signing you acknowledge all information is truthful

Category: Employment Questionnaire

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