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