Staff Health Questionnaire

Full Name

Date of Birth

Contact Number

GP Name

GP Address

GP Contact Number

NHS Number

Date of last Flu vaccination

Dates of Covid-19 vaccinations

Do you have, or have you ever had any significant illness? (i.e. Asthma, Diabetes, Heart Disease, Other) [Yes or No] If yes, please give details

Are you regularly seeing your GP for any ongoing health condition? [Yes or No] If yes, please give details

Are you on a waiting list to see a specialist, or have you seen one in the past 5 years? [Yes or No] If yes, please give details

Have you had any hospital admissions in the last 5 years? [Yes or No] If yes, please give details

Have you ever had any illness/impairment/disability which may have been caused by, or made worse by your work? [Yes or No] If yes, please give details.

Are you aware of any other medical problems you have that may cause you difficulty in performing your normal working role or attending work? [Yes or No] If yes, please give details

Do you think you may need any adjustments or assistance in order for you to undertake your normal working duties? [Yes or No] If yes, please give details

Are you regularly taking any prescription medication? [Yes or No] If yes, please give details

Are there any other matters concerning your health not covered by the previous questions, which we should know about? [Yes or No] If yes, please give details

To the best of my knowledge and belief the information given above is true and correct

Yes

Please be advised, Manuel Divine Care Ltd will ensure the confidentiality of ALL information provided in this document is maintained and

ONLY accessed in an emergency situation. Where required, any reasonable adjustments and/or risk assessments will be implemented and regularly reviewed on an individual basis to ensure you are safeguarded at all times.