Major Healthcare Health Declaration Form

Please select your nearest branch *

1. Personal Details

Name *

First

Last

Previous name(s) known by

First

Last

Title

Gender

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile

Telephone

Email

2. Position applied for

Title of the position you have applied for

This job may involve

Please tick all that apply

For night shift workers only:

How long have you been working nights?

What type of work?

Have you suffered any health problems that are directly related to working night shifts? Please state:

3. Work Related History

Have you been absent from work or full-time study due to long-term ill health during the last 12 months?

Yes
No

Please give details

Have you ever left or been denied a job on health grounds?

Yes
No

Please give details

Have you ever been denied a driving licence on health grounds?

Yes
No

Please give details

Have you ever suffered from any work-related health conditions?

Yes
No

Please give details

Have you ever had an accidental sharps injury or exposure to blood/bodily fluids with broken skin or mucous membranes?

Yes
No

Please give details

Please state: • Date of the incident • Status of source if known • Details of treatment given at time of injury • Details of follow up blood test results/surveillance

4. Health History

Conditions of the lungs? (Asthma/bronchitis/pleurisy/tuberculosis/other chest complaints/coughing up blood/shortness of breath/etc)

Yes
No

Please give details

Conditions of the heart? High blood pressure/heart attacks/angina?

Yes
No

Please give details

Nervous system disorder? Blackouts/epilepsy/muscular weakness/paralysis?

Yes
No

Please give details

Migraine or persistent headaches?

Yes
No

Please give details

Conditions of the digestive system? Irritable bowel syndrome/Crohn’s disease/liver complaints/jaundice/colitis/gastric/duodenal ulcer?

Yes
No

Please give details

Conditions of the bones, joints and limbs? Arthritis/rheumatism/back problems/neck and shoulder problems/sciatica/upper limb disorder/tennis elbow/any other conditions?

Yes
No

Please give details

Allergies? (Including allergies to drugs, animals and pollens/hayfever)

Yes
No

Please give details

Skin conditions? Eczema/dermatitis/psoriasis/recent infection/skin cancer?

Yes
No

Please give details

Gland trouble? Diabetes/thyroid – overactive/underactive?

Yes
No

Please give details

Eye conditions? Restricted vision/glaucoma/iritis/cataracts/macular degeneration/any other conditions?

Yes
No

conditions? contact you

Please give details

Ear conditions? Restricted hearing/tinnitus/ear infections?

Yes
No

Please give details

Alcohol or drug problems? Problems related to alcohol or drug usage or dependency?

Yes
No

Please give details

Mental illness and/or stress related problems? Nervous breakdown/mental fatigue/anxiety/depression/panic attacks/significant sleep disturbance/stress related problems/eating disorders/self harm/any other conditions?

Yes
No

Please give details

Have you consulted a specialist or need any operations other than already stated?

Yes
No

Please give details

Have you spent any time in hospital other than already stated?

Yes
No

Please give details

Have you consulted your GP in the last 12 months? If so, please state why.

Yes
No

Please give details

Are you receiving medical treatment at the present time?

Yes
No

Please give details

Do you take any regular medication?

Yes
No

Please give details

Are you aware of having any disability that is covered by the Disability Discrimination Act?

Yes
No

Please give details

Have you any disabilities affecting sight, hearing, standing, sitting, walking, lifting, driving, stair climbing, use of the hands or ability to carry out any work indicated in section 2?

Yes
No

Please give details

Have you been in contact with MRSA? If Yes – did you contact Occupational Health? Please detail the treatment you received and state whether you have been cleared. You are required to inform the company immediately should you come into contact with MRSA.

Yes
No

Please give details

Have you any other health issues that have not been mentioned above or about which you would like to provide further details?

Yes
No

Please give details

5. Vaccination History

To reduce the need for further blood tests, please provide a laboratory report or certificates signed and dated for your GP/ Vaccinated Centre or Occupational Health Department as evidence of any of the immunisations you have had as listed below:

Hepatitis B primary course

Hepatitis B booster (s)

Hepatitis B antibody blood test

Varicella (proof of immunity)

Diphtheria (proof of 10 yearly update/booster)

Poliomyelitis (proof of 10 yearly update/booster)

Tetanus (proof of 10 yearly update/booster)

Rubella (proof of immunity)

Measles (proof of immunity)

Mumps (proof of immunity)

TB skin test e.g. Heaf test

BCG (protection against TB)

HIV (negative result for exposure prone procedure)

Hepatitis C (negative result for exposure prone procedures)

Hepatitis B Surface Antigen (for exposure prone procedures)

Evidence of vaccination(s)

Drag & Drop Files, Choose Files to Upload You can upload up to 30 files.

6. General Practitioner details

GP Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

7. Declaration

Declaration from worker *

I declare that the information give within this declaration of health is true and complete to the best of my knowledge. I understand and accept that I may be required to attend for an Occupational Health Assessment. I understand and accept that further medical information may be requested from my doctor if considered necessary. I understand that making false statements or failure to declare health problems could lead to removal from the Agency’s register. I agree to update this declaration of health on an annual basis.

Signature

Clear Signature