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Major Healthcare Health Declaration

Please select your nearest branch:

Name:

Previous name(s) known by:

Title:

Gender:

Address:

Mobile:

Telephone:

Email:

Title of the position you have applied for:

This job may involve:

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::

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

Please give details:

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

Please give details:

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

Please give details:

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

Please give details:

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

Please give details:

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

Please give details:

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

Please give details:

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

Please give details:

Migraine or persistent headaches?:

Please give details:

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

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?:

Please give details:

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

Please give details:

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

Please give details:

Gland trouble? Diabetes/thyroid – overactive/underactive?:

Please give details:

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

Please give details:

Ear conditions? Restricted hearing/tinnitus/ear infections?:

Please give details:

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

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?:

Please give details:

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

Please give details:

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

Please give details:

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

Please give details:

Are you receiving medical treatment at the present time?:

Please give details:

Do you take any regular medication?:

Please give details:

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

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?:

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.:

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?:

Please give details:

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):

GP Name:

Address:

Declaration from worker:

Signature:

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.

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Timestamp

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20th March 2026 11:12 am BST

Major Healthcare Health Declaration Uploaded by No-Reply Major Recruitment - onlineterms@major-recruitment.com IP 94.12.146.81