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Your Health Questionnaire
Welcome to Salvere Support
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Health Questionnaire
It is important for us to be aware of any health conditions or issues that may have an impact on your employment and ability to work. This is particularly important where you have a qualifying disability under the Equality Act 2010, as it will enable us to identify what, if any “reasonable adjustments” can be made. Information collated in the form will be held on your personal file.
Your Details
Your Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Phone
*
Email
*
Date of Birth
*
What is your sex?
*
As shown on your birth certificate or gender recognition form, or state "prefer not to say".
Your Doctor's Details
GP Name
*
First
Last
GP Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
GP Phone
*
Next of Kin Details
Next of Kin Name
*
First
Last
Does your next of kin live at your home address?
*
Yes
No
Next of Kin Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Next of Kin Phone
*
Next of Kin Email
Health Information
Please tell us anything we need to know about your health that may affect you in your role so we can make any reasonable adjustments and support you in your employment. If we don't know, we can't provide the right support.
Do you have, or have you had, physical or mental health problems lasting 3 weeks or longer?
Yes
No
Please provide details:
Have you ever had a health problem that may reoccur in the future?
Yes
No
Please provide details:
Are you taking any prescribed medication at present? (do not answer ‘yes’ for birth control medication)
Yes
No
Please provide details and is it required to be taken on a strict timetable?
Do you need any aids or adaptations to carry out day-to-day activities?
Yes
No
Please provide details:
Are you restricted for health reasons from carrying out any specific types of work?
Yes
No
Please provide details:
In the last 5 years have you ever had any serious illness, operation, accident or hospital treatment?
Yes
No
Please provide details:
Are you currently pregnant or have recently given birth?
Yes
No
Please provide details:
Do you require adjustments to your proposed work in relation to pregnancy or disability?
Yes
No
Please provide details:
Have you had any absence from work, of three weeks or longer, due to illness or injury in the last 12 months?
Yes
No
Please provide details:
Do you have any known medical condition, which would require you taking sickness absence in the next 12 months?
Yes
No
Please provide details:
Please read the job description provided. Do you have any health problems that could be affected or made worse by the activities identified?
Yes
No
Please provide details:
Is there any additional information regarding your health not covered in the questions above that may be relevant to your role?
Yes
No
Please provide details:
Declaration
*
I know of no health reasons (other than those discussed and agreed in relation to my legal rights under the Equality Act 2010) which will affect my ability to undertake the duties of the post. All the answers on this form are true and correct to the best of my knowledge. I understand that if, at a later date, it is discovered that I have knowingly withheld medical information, disciplinary action may be taken against me which may include dismissal.
Submit
