The purpose of this Health Assessment questionnaire is to establish your medical fitness for work. In most instances
this can be decided from the information given in this questionnaire. If, however, further details are required, you
may be contacted by an Occupational Health Advisor, or requested to attend a medical examination with an
Occupational Physician. It is in your interest, as well as that of Hays, that all the questions are answered accurately.
This will enable us to make arrangements for your placement as soon as possible. All medical information will be
treated as CONFIDENTIAL unless your consent is given to release the information.
This Health Assessment forms part of the Hays registration documentation and will be processed in accordance with
our data protection statement and policy. For the purposes of assessment this questionnaire may be passed in
confidence to a third party specialist occupational health service.
Please complete this form fully and bring it with you to your interview with your Hays Consultant.
Name Position sought
Do you suffer from or have you ever suffered from any of the following:
Mental ill health, anxiety, depression or stress Yes/No Recurrent ear/nose/throat infections Yes/No
Fits, blackouts, epilepsy, giddiness Yes/No Sensitivities or allergies Yes/No
Respiratory problems Any other disease or injury
(asthma, tuberculosis, bronchitis etc) Yes/No (other than normal childhood illness) Yes/No
Heart disease, high blood pressure Yes/No Have you ever been admitted to hospital? Yes/No
Hepatitis or jaundice Yes/No Have you had any operations? Yes/No
Kidney/bladder disease Yes/No Have you had any sickness absence in the
last two years? Yes/No
Bone/joint disease Yes/No
Are you taking any medication? Yes/No
Rheumatic fever Yes/No
Have you been rejected/retired on medical
grounds from any previous job? Yes/No
Back or neck problems Yes/No
Have you ever had any treatment or
Neurological problems Yes/No counselling for solvent misuse, drug or
alcohol problems? Yes/No
Dysentery, food poisoning or recurring diarrhoea Yes/No
Have you ever had a health problem which
Typhoid or Paratyphoid fever Yes/No
has been made worse by work? Yes/No
Visual impairment Yes/No
Do you have any disabilities for which you
Hearing impairment Yes/No would require adjustments in order to
undertake the duties for which you are likely
Skin problems (eczema, dermatitis etc) Yes/No
to be employed? Yes/No
If you have ticked “yes”to any of the above, please provide details, including dates and duration.
I declare that I have checked the details I have given and to the best of my knowledge they are correct. I realise that any
deliberately false statements or omissions may be treated by Hays as reason to refuse me work or terminate my assignment. I
understand that I may be requested to attend a medical examination.
I know of no reason why I would not be considered fit or suitable to work with children. I undertake to notify Hays immediately
should I become aware of any circumstances which may affect my fitness to work with children.
hays.co.uk/education Page 1 CAF4HEDHA (04/10)