Your first name
Your last name
Position Offered
Date of Birth
Have you ever had Tuberculosis, asthma, bronchitis or chest problems?
Additional information to “Yes” response
Have you ever had Chest pain, heart condition or raised blood pressure?
Additional information to “Yes” response
Have you ever had Blackouts, fits or attacks of giddiness?
Additional information to “Yes” response
Have you ever had Depression, mental illness or nervous breakdown?
Additional information to “Yes” response
Have you ever had Rheumatism or arthritis?
Additional information to “Yes” response
Have you ever had Back trouble?
Additional information to “Yes” response
Have you ever had Typhoid or paratyphoid?
Additional information to “Yes” response
Have you ever had Digestive or bowel disease?
Additional information to “Yes” response
Have you ever had Diabetes, thyroid or other gland trouble?
Additional information to “Yes” response
Have you ever had Bladder or kidney trouble?
Additional information to “Yes” response
Have you ever had Dermatitis or skin trouble?
Additional information to “Yes” response
Have you ever had Varicose veins?
Additional information to “Yes” response
Have you ever had any other accident, operation or illness?
Additional information to “Yes” response
Have you any reason to believe you may be infected with any communicable disease?
Additional information to “Yes” response
Have you ever had any other current or recent medical condition or treatment which might affect your attendance or performance at work?
Additional information to “Yes” response
Do you intend to work night duties on a regular basis?
Additional information to “Yes” response
Has any illness or medical condition prevented you from attending work on your normal duties or activities for more than one week during the past year? If yes, please specify
Additional information to “Yes” response
Do you have any physical or mental impairment which has a substantial and long term effect on your ability to carry out day to day activities? If yes, please specify any special adjustments required in relation to work.
Additional information to “Yes” response
Additional information to “Yes” response
How many units of alcohol do you drink per week? (one unit = 1 middy beer = 1 glass wine = 1 shot of spirits)
Additional information to “Yes” response
Submit Health Questionnaire
