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Albert Bartlett Occupational Health Form

INITIAL ON STARTING THE COMPANY

UPDATE ONLY (Tick if update only)

Title

Mrs

Miss

Other

Surname

Forename(s)

Main Reason for update (If Applicable)

Please tick the box which is most relevant. If the answer to any of the questions is ‘YES’, please give details.

Do you consider yourself to be disabled under the terms of the Equality Act 2010?

Yes

Have you been medically examined in the past two years in hospital or by a Specialist Doctor?

Yes

Are you taking any regular medicine(s) as prescribed by a G.P?

Yes

Have you or anyone in your household suffered from diarrhoea and/ or vomiting within the last 2 weeks where symptoms persisted for 24 hours or more?

Yes

Have you been absent from work in the last twelve months?

Yes

Do you suffer with dyslexia or have difficulty with reading, writing or numeracy?

Yes

If you have been outside the UK within the last 3 months please state where. Have you suffered from any illness since?

Yes

Do you suffer from, or have you ever had any of the following:-

Severe, frequent or prolonged headaches, migraines?

Yes

Enteric fever, typhoid or paratyphoid?

Yes

Recurrent chest problems e.g. bronchitis or sneezing?

Yes

Fits, blackouts or dizzy spells?

Yes

Eye diseases or problems with your vision including colour blindness?

Yes

High / Low blood pressure?

Yes

Neurological problems (epilepsy, sleep deprivation, Bells palsy, stroke, multiple sclerosis)?

Yes

Asthma, hay fever, shortness of breath (do you use an inhaler)?

Yes

Heart or circulatory illness, varicose veins?

Yes

Skin problems or diseases (e.g. eczema, dermatitis, warts, psoriasis, acne, septic spots or nail infections)?

Yes

Infections of, or discharge from the ears, eyes, gums, nose or throat?

Yes

Frequent sore throats?

Yes

Chronic pain issues (IBS, Arthritis, Spinal or back pain, sciatica, Carpal Tunnel, Osteoarthritis, Crohn’s disease, repetitive strain injury)?

Yes

Problems with your hands, arms, legs or feet which affect movement or normal use?

Yes

Diabetes (Type 1 or Type 2)?

Yes

Mental health or nervous troubles, depression, or anxiety, (even if mild)?

Yes

Do you wear spectacles or contact lenses?

Yes

Do you have any hearing impairment or wear anything to aid with hearing?

Yes

Do you drink alcohol? If yes, indicate how many glasses of wine, beer or spirits you drink each week?

Yes

Have you ever consulted your doctor about a substance misuse/abuse (this includes alcohol)?

Yes

Do you smoke? If yes, indicate how much tobacco or how many cigarettes you smoke?

Yes

Do you have a peanut allergy? Do you require to carry an epipen?

Yes

Do you have any other allergies? Do you require to carry an epipen?

Yes

Have you ever had an accident at work? (past or present employment)

Yes

Please provide details of any other relevant information about your health including whether you have any requirements to carry any medication on your person such as an inhaler or an epipen.

PLEASE NOTE: If you have a medical condition such as asthma, diabetes or epilepsy it is your responsibility to provide this information to the nearest Company First Aid Personnel in your work area.

I declare that the information I have provided above is true and is to the best of my knowledge. I am aware that any false information may affect my employment with Albert Bartlett. I also agree to inform my Team Leader or Line Manager if I become unwell or I am found to be suffering from an infectious disease.

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Timestamp

Audit

18th August 2025 12:46 pm BST

Albert Bartlett Occupational Health Form Uploaded by No-Reply Major Recruitment - onlineterms@major-recruitment.com IP 185.241.227.224

18th August 2025 1:21 pm BST

ID Recruitment - info@id-recruitment.co.uk added by No-Reply Major Recruitment - onlineterms@major-recruitment.com as a CC'd Recipient Ip: 185.241.227.224