Welcome.
Please login to edit your website.
Username or Email Address
Password
Remember Me
Log In
Pre-employment Questionnaire
"
*
" indicates required fields
First Name
*
Family Name
*
Nationality
*
Company / Business Name
Date of Appointment if known
DD slash MM slash YYYY
Date of birth
*
DD slash MM slash YYYY
Gender
*
Male
Female
Other
Address
*
Email
*
Mobile
Family GP
Position Applied For
Former Occupation(s)
Please provide some detail concerning previous jobs in which you have worked.
Employer / Company Name
Brief Job Description
Employer / Company Name
Brief Job Description
Employer / Company Name
Brief Job Description
Employer / Company Name
Brief Job Description
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
*
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
Signature…………………….. Date ……………………
( to be signed when attend for examination )
Time
:
AM
PM
AM/PM
Phone
This field is for validation purposes and should be left unchanged.
Employer Referral Form
"
*
" indicates required fields
For use only by Employers with prior agreement/ arrangement with Catherine Street Medical Centre.
Company Name
HR Manager
Mobile No
*
Tel No
Email
*
Employee First Name
*
Employee Family Name
*
Date of Birth
*
Gender
*
Male
Female
Other
Contact Number
*
Occupation
*
Length of time in current position
*
Duties
*
Family Doctor
*
Reason for Assessment
Matters to be addressed
Has employee been assessed here before?
*
Yes
No
Email
This field is for validation purposes and should be left unchanged.
Skip to content
Open toolbar
Accessibility Tools
Increase Text
Decrease Text
Grayscale
High Contrast
Negative Contrast
Light Background
Links Underline
Readable Font
Reset