Online Health Questionnaire
Name
Position
Your Doctors Name:
Height:
Weight:
Back Pain:
Yes No
Neck Pain:
Yes No
Rheumatic or arthritic condition
Yes No
Hernia:
Yes No
Upper limb disorder such as tenosynovitis, tendononitis or carpal tunnel syndrome:
Yes No
Fits, fainting or epilepsy :
Yes No
Depression, anxiety or nervous illness or have been referred for psychiatric assessment
Yes No
Typhoid, paratyphoid, dysentery or food poisoning :
Yes No
Tuberculosis or hepatitis :
Yes No
Any medical condition not specified above :
Yes No
Have you ever been absent from work as a consequence of any of the above :
Yes No
Are you currently on medication :
Yes No
Have you ever taken time off work due to an accident at work :
Yes No
Have you ever been in receipt of compensation or State benefit as a consequence of an illness or an injury arising from work :
Yes No
I declare the answers to the above questions are true, that I am now in and usually enjoy good physical and mental health. I understand that the non-disclosure of any suppression of any relevant facts know to me may prejudice my employment within the company and may lead to dismissal.
I agree that a medical report may be obtained from my doctor or hospital specialist
Signature :
Date :
 
Personal Care Should you choose to use 'All About You' as the provider of your Personal Care Se Read more......
Specialist Support We understand living with long-term conditions and experiencing episodes of incapacity often Read more......
Direct Payments Because services are person centred and tailored to your needs costs will vary... Read more......
Areas of Operation The areas we currently operate in and provide services include: Read more......
Practical Help ...these services are aimed at maintaining a quality living environment rather than.... Read more......