Pre Employment Health Check by eyg87181

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Pre Employment Health Check document sample

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									                                                                              HRM Homecare Services Ltd



                                                                            HEALTH DECLARATION FORM




         1. HEALTH

 MEDICAL HISTORY Any offer of employment will be subject to a satisfactory health check. You are therefore required
 to complete this PRE-EMPLOYMENT HEALTH CHECK FORM.

                                                  NO    YES                            Details

  1   Do you have any impairment which may
      affect your ability to work safely?
  2   Have you been seen or examined by a
      doctor in the last six months?
      Are you having regular treatment or
  3
      waiting for investigations of any kind at
      the moment?
      Do you have an eyesight problem not
  4   corrected by glasses? E.g. colour
      blindness
  5   Do you have any hearing problems not
      corrected with a hearing aid?
      Do you have any difficulty in standing,
  6
      bending, lifting, and kneeling on the
      floor or other movements?
  7   Have you ever had any kind of back
      problem?
      Have you ever had any kind of
  8
      problems with your joints including pain,
      swelling or restricted movement?
  9   Have you ever had any kind of skin
      conditions?
      Have you ever had diabetes, thyroid or
 10   gland problems or receive treatment for
      these?
 11   Have you ever had fits/seizures,
      blackouts or epilepsy?
 12   Have you ever had asthma, bronchitis,
      breathing difficulties or chest problems?
 13   Have you ever had Tuberculosis (TB)?
      In the last 12 months have you had a
 14   cough for more than three weeks, ever
      coughed up blood or had any
      unexplained loss of weight or fever?
      Have you ever sought help for any
 15
      mental health issues, stress,
      psychological or emotional problems?
 16   Have you ever needed a course of
      counselling?

 17   Have you ever taken an overdose or
      deliberately harmed yourself?

               in any way

Registered in Scotland No. SC 167583, Registered Address: 75 London Road, Kilmarnock
KA3 7BP, Tel: 01563 570980Fax: 01563 570981 / 570982 info@hrmhomecare.co.uk, www.hrmhomecare.co.uk         HRM-OF-264
                                                                              HRM Homecare Services Ltd



                                                                            HEALTH DECLARATION FORM




 18   Have you ever received treatment for
      gastric, stomach or bowel problems?
      Have you ever had heart, circulatory or
 19   blood pressure problems?
      Please explain

      Have you ever had a drug or alcohol
 20   problem? Did you receive treatment?

      Please explain
      Do you suffer from any sleep disorder,
 21   such as insomnia, narcolepsy or
      dyssomnia?
 22   Do you have any allergies?

 23   Have you ever had hepatitis or
      jaundice?
 24   Do you have any other medical
      condition?
      Have you ever had any illness which
 25   may have been caused or made worse
      by your work?
 26   Do you smoke? If yes, how many per
      day?
      Do you drink? If yes, how many units
      due you consume each week?
 27
      e.g. 1 unit is equivalent to a ½ pint of
      beer/lager, 1 shot or a small glass of
      wine (125 ml)
 28   Have you ever been ill-health
      retired/medically dismissed?
 29   Have you ever had any disorders of the
      bladder or kidney?
      Have you ever had any industrial
 30   accidents or occupational diseases or
      any illness which may have been
      caused by work?
      Do you have any physical or mental
      impairment which may affect your ability
 31   to work safely?
      If yes, what is the nature of your
      condition?




Registered in Scotland No. SC 167583, Registered Address: 75 London Road, Kilmarnock
KA3 7BP, Tel: 01563 570980Fax: 01563 570981 / 570982 info@hrmhomecare.co.uk, www.hrmhomecare.co.uk   HRM-OF-264
                                                                                       HRM Homecare Services Ltd



                                                                                      HEALTH DECLARATION FORM




 Would you consider yourself to have a disability?                Yes        No 

 If yes, what is the nature of your disability?




          2. FAMILY HISTORY

 Please list any serious illnesses that have happened to your immediate family (i.e. parents, siblings and/or children).




          3. HEALTH DECLARATION



 I declare that the foregoing statements are true and complete to the best of my knowledge. I am aware that I will be held
 responsible for the accuracy of this Declaration and that if any answer is found to be false or any relevant fact has been
 willfully suppressed my contract may be invalidated. I agree that I will disclose any occurrence affecting my health after
 the signature date.




  Signature: --------------------------------------------------------------   Date: …………………………………




Registered in Scotland No. SC 167583, Registered Address: 75 London Road, Kilmarnock
KA3 7BP, Tel: 01563 570980Fax: 01563 570981 / 570982 info@hrmhomecare.co.uk, www.hrmhomecare.co.uk                HRM-OF-264
                                                                                 HRM Homecare Services Ltd



                                                                               HEALTH DECLARATION FORM




         4. PREVIOUS SICKNESS ABSENCE (time lost from work duties due to illness over the last two
            years)

                  Length of Absence                                           Reason for Absence




         5. NIGHT HEALTH CARE ASSESSMENT

 (For the purpose of this agreement a night worker is considered to be an individual who performs at least 3 hours of
 their shift between the hours of 10 pm and 8 am.)



 Night work may affect such conditions as: Diabetes; Sleep Disorders; Cardiovascular and Gastro Intestinal problems
 among others.



 To the best of your knowledge, do you have any condition/ailment, which may be adversely affected by your
 participation in night work?      Yes          No 



 If Yes, what is your complaint?




         6. ACCESS TO MEDICAL RECORDS ACT 1988

         Summary of your rights under the Act

         1. You can withhold your consent to the report being provided.

         2. You have 21 days in which to ask your doctor to show you the report before he sends it to our
            Corporate Medical Advisor (and you may pay for a copy if you wish)

         3. You can ask the doctor either to amend any part of the report considered by you to be misleading
            or, if the doctor does not agree to change it, you may add your own comment to the report. You
            may also withdraw your consent at that time.

         4. There are certain circumstances under which the doctor may withhold the report from you, if such
            action is felt to be in your best interests.




Registered in Scotland No. SC 167583, Registered Address: 75 London Road, Kilmarnock
KA3 7BP, Tel: 01563 570980Fax: 01563 570981 / 570982 info@hrmhomecare.co.uk, www.hrmhomecare.co.uk              HRM-OF-264
                                                                                           HRM Homecare Services Ltd



                                                                                          HEALTH DECLARATION FORM




         5. If you decide at the moment not to see the report you will still have six months in which to change
            your mind and to contact your doctor for a copy of the report. If you indicate on the consent form
            below that you do not wish to see the report then your doctor can send it to our Corporate Medical
            Adviser immediately.

                                                        CONSENT FORM

         I hereby consent to a medical report being supplied in confidence by my Doctor and/or Consultant Specialist (if
         applicable) to the Corporate Medical Adviser of HRM Homecare Services Ltd. I have been informed of my
         statutory rights under the Access to Medical records Act 1988 and have read the summary of my principal rights
         under the Act as set out above.



         My Doctors name and full postal address is:

         ………………………………………………………………………………………..

         …………………………………………………………………………………………………………………………………..

         …………………………………………………………………………………………………………………………………..



         My name and full postal address of my Consultant Specialist, if applicable is:

         ..………………………………………………..

         ………………………………………………………………………………………………………………………………….



         …………………………………………………………………………………………………………………………………..



         Your full name: …………………………………………………………

         Date of Birth:

         Address:
         ….……………………………………………………………………………………………………………………………….



         ……………………………………………………………………………………………………………………………………



         ……………………………………………………………………………………………………………………………………



         Signature: ……………………………………………………………….



         Date: ………………………………………………..



Registered in Scotland No. SC 167583, Registered Address: 75 London Road, Kilmarnock
KA3 7BP, Tel: 01563 570980Fax: 01563 570981 / 570982 info@hrmhomecare.co.uk, www.hrmhomecare.co.uk                         HRM-OF-264

								
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