Pre-employment Questionnaire online - Enniscorthy Medical Centre

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Pre-employment Questionnaire online

Pre-employment Questionnaire

First Name *

Family Name

Phto Upload

Maximum file size: 8MB

Nationality *

Date of birth *

Address *

Email

Mobile

Landline

Family GP

Position Applied For

Former Occupation(s)
Please provide some detail concerning previous jobs in which you have worked.

Date

Brief Job Description

Inidicate wheather any exposure to chemicals, dust or noise

Date

Brief Job Description

Inidicate wheather any exposure to chemicals, dust or noise

Date

Brief Job Description

Inidicate wheather any exposure to chemicals, dust or noise

Date

Brief Job Description

Inidicate wheather any exposure to chemicals, dust or noise

Please answer yes or no to the following questions. If yes please give details.

Do You Smoke? *

Yes

No

If yes please indicate quantity *

Do you drink alcohol? *

Yes

No

One unit of alcohol is equivalent to one half pint of beer, one glass or wine or one measure of spirit.

If yes please indicate quantity *

Do you exercise or play sport? *

Yes

No

If yes please supply more information

Have you ever been treated for or had counselling/therapy for an addictive disorder involving drugs or alcohol? *

Yes

No

If yes please supply more information

Have you ever been refused work on health grounds? If yes please give details *

Yes

No

If yes please supply more information

Have you ever retired or had to give up work on health grounds? *

Yes

No

If yes please supply more information

Have you attended any doctor for any problem in the past 5 years *

Yes

No

If yes please supply more information

Are you currently taking medication? *

Yes

No

If yes please supply more information

Are you having any symptoms or illness investigated currently? *

Yes

No

If yes please supply more information

Have you ever had an illness or disability that may affect you ability to carry out you duties safely and to a high standard? *

Yes

No

If yes please supply more information

Have you taken sick leave in the past 3 years? *

Yes

No

If yes please supply more information

Have you ever had or do you currently have:

Pulmonary or respiratory problems? e.g. asthma, bronchitis, wheezing, TB, pneumonia *

Yes

No

If yes please supply more information

Ear, Nose and throat disorder? e.g. hearing difficulty, difficulty with balance, vertigo, tinnitus, ability to smell, rhinitis, hay fever, voice etc *

Yes

No

If yes please supply more information

Heart and circulation problems? e.g. anaemia, blood pressure, angina, heart attack, cold or numbness of hands or feet, varicose veins, etc. *

Yes

No

If yes please supply more information

Diabetes or thyroid disorders etc? *

Yes

No

If yes please supply more information

Nervous system problems? e.g. epilepsy, fits, faints, blackouts, stroke, headaches, migraine, power loss, numbness, pins and needles etc *

Yes

No

If yes please supply more information

Eye problem? e.g. visual loss, colour blindness, glaucoma, cataracts, double vision, field defect etc *

Yes

No

If yes please supply more information

Skin disorder? e.g. eczema, dermatitis, psoriasis, rashes etc *

Yes

No

If yes please supply more information

Digestive problems? e.g. ulcers, gastritis, irritable bowel, crohn’s disease, ulcerative colitis, pancreatitis, liver disease, gall bladder disease etc *

Yes

No

If yes please supply more information

Allergies? e.g. medication, chemicals, irritants, cleaning agents, foods etc *

Yes

No

If yes please supply more information

Musculoskeletal disorders e.g. neck, back and joint problems, slipped discs, trapped nerves, scoliosis, torn ligament or cartilage, rheumatism, fibromyalgia etc. *

Yes

No

If yes please supply more information

Overuse injury? e.g. tendonitis, tennis elbow, golfers elbow, frozen shoulder, repetitive strain injury (RSI), work related upper limb disorder WRULD) etc

Yes

No

If yes please supply more information

Urinary problems? e.g. urinary infections, incontinence, kidney stones, prostatism, prostatitis, etc *

Yes

No

If yes please supply more information

Female health problems? *

Yes

No

If yes please supply more information

Tumours – benign and malignant. *

Yes

No

If yes please supply more information

Psychiatric or psychological problems? e.g. anxiety, depression, panic attacks, nervous breakdown, burnout, schizophrenia, eating disorder, anorexia, bulimia etc *

Yes

No

If yes please supply more information

Accidents, injuries or illness not already noted? *

Yes

No

If yes please supply more information

I understand that the purpose of this pre–employment questionnaire is to confirm that:

I am fit for the position I have applied.
I can perform my duties safely and without risk to the health and safety of others.
I can render reliable and productive service for my employer

I declare that the information I have given is true and accurate to the best of my knowledge and that I have not withheld any material facts. I understand that I am responsible for the accuracy or otherwise of the answers above. I understand that if I have knowingly withheld material facts this may affect my appointment.

Tick box to indicate that you understand and agree with the declaration. *

I agree to the above

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If you are human, leave this field blank.

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