Medical Questionnaire

Medical Questionnaire

Do you, or have you ever, had any of the following conditions?

Please disclose any condition which has the potential to affect your ability to carry out your onsite duties safely; without affecting the safety of others on site.

If your answer is yes to any please provide full details.

* Required

Asthma, bronchitis, emphysema, pleurisy, pneumonia or any other lung disease including TB or pneumothorax disorder *
Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness *
Any problems with bones or joints including back, neck, knee, sciatica, any fracture, or recurrent dislocation of a major joint *
Chest pain, angina, heart disease or breathlessness *
Any visual defect e.g. scotoma, blindness in one eye, night blindness, colour blindness, reduced visual field, blurred vision or detached retina *
Ear infection, discharge, tinnitus, a hearing defect including deafness *
Any metabolic disorder including diabetes, thyroid and adrenal gland disease or other glandular disorder *
Do you have any Physical condition or illness that could prevent you from attending work for a lengthy period of time? *
Current treatment. Are you currently attending a hospital/GP for treatment or waiting for an appointment? *
Do you have a disability which may affect your ability to undertake the position you have applied for? The Disability Discrimination Act 1995 defines a person with a disability as "A physical or mental impairment which has a substantial adverse long term effect on his or her ability to carry out normal day to day activities" *
Do you have any condition that could affect your ability to work night shifts? *
Are you currently taking any prescribed tablets or medication or receiving injections (excluding contraception or HRT)? *
Criminal Declaration
Do you have any unspent criminal convictions? *

I declare that the information I have given is true and correct and I consent to this data being held on a computer or in a manual filing system in accordance with the confidentiality requirements of the Data Protection Act 1998.

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Emergency Contact

If any of this information changes whilst I am employed by/return to work for Compass Resourcing, I will notify a member of staff immediately. Please be aware that any false information given could result in your contract being terminated.

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