An employee health questionnaire helps the employer to get an idea about the health conditions of the employee. This document helps the employer to assess whether the employee would be able to carry out his assigned duties effectively.

It also establishes the fact that whether the employee has any health hazards. All the questions answered in the questionnaire are checked by a doctor. The answers are always kept confidential.

Sample Employee Health Questionnaire

Please complete this questionnaire. All the information provided by you will be kept confidential.

Name: _________________

Middle Name: ______________

Surname: __________________

Designation: _________________

Date of Birth: _________________

Address: ____________________

Telephone Number: ______________

Department: ____________________

Please tick on the appropriate option if you have any history of the below mentioned health conditions:

  1. Cardiovascular Disease:     Yes         No
  1. Diabetes:                             Yes        No
  1. Mental Disability:               Yes        No
  1. Alcoholism:                         Yes       No
  1. Allergies:                             Yes       No
  1. Physical disability:               Yes      No

Please answer the questions correctly:

Are you currently on any kind of medication? ___________________________

Did you ever have to undergo surgery? ___________________________

If yes, what kind to surgery was that? _________________________

Is there any health condition that affects your ability to work? ____________________

Do you have any hearing problem? _________________________________

Do you have any eye related problems? _________________________________

Do you wear spectacles? _____________________________________

Is there any family history of spondylitis? _______________________

Is there any family history of heart ailment? ________________________

I hereby declare that all the information provided by me in this questionnaire is true.

I understand that any distortion of fact can result in losing my job and lead to termination from my employment.

Employee’s Signature __________________________

Date _____________________________________