Health and Safety

Employee Induction Handbook

Employee Health Questionnaire

Do you have or have you ever had any of the following:
Heart attack, angina, raised blood pressure or other heart problems? YES   NO ✓

 
Fits, epilepsy, blackouts or vertigo? YES   NO ✓

 
Asthma, bronchitis or other chest diseases? YES   NO ✓

✓
Diabetes, thyroid disease or other gland disorders? YES   NO  

✓
Hepatitis, jaundice or blood disorders? YES   NO  

✓
Disorder of bladder or kidneys? YES   NO  

✓
Digestive or stomach conditions. e.g., ulcer? YES   NO  

✓
Skin conditions, e.g., eczema? YES   NO  

✓
Any form of allergy at home or at work e.g., plants, hay fever, drugs? YES   NO  

✓
Hernia (rupture) varicose veins? YES   NO  

✓
Back pain, back injuries or back conditions at home or at work? YES   NO  

✓
Neck, hands, arms, legs or feet conditions which affects movement or YES   NO  
normal use in or out of work?

✓
Joint conditions, arthritis, rheumatism? YES   NO  

✓
Severe, frequent or prolonged headaches or migraine? YES   NO  

✓
Learning disabilities such as dyslexia, difficulties reading or writing? YES   NO  

✓
Mental illness, psychological or psychiatric problem illness including YES   NO  
depression, anxiety, nervous debility or breakdown, or schizophrenia?

✓
A drug or alcohol problem? YES   NO  

✓
Hearing conditions or problems? YES   NO  

✓
Any eye conditions, colour blind, not corrected by glasses? YES   NO  

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 Health and Safety
Employee Induction Handbook

✓
Do you wear corrective glasses or contact lenses? YES   NO  

✓
Tuberculosis (TB) YES   NO  

✓
Any health condition which you perceive may be caused or made worse by YES   NO  
work?

✓
Any other health conditions which you perceive may require adjustments YES   NO  
in the workplace?

Please answer the following questions

✓
Have you ever been medically retired from any job, or left any job because YES   NO  
of ill health?

✓
Are you aware of having a disability or impairment which is long standing YES   NO  
and affects your daily activities of living? See definition above.

✓
Do you believe that any adjustments are likely to be needed to enable you YES   NO  
to effectively carry out all of your duties? Please provide details below.

✓
Are you presently receiving any prescribed medication, treatment or YES   NO  
therapy

✓
Are you waiting for any treatment, operation or investigations? YES   NO  

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 Health and Safety
Employee Induction Handbook

Employee Health Questionnaire

IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS PLEASE GIVE DETAILS BELOW

             
 
   
   
 
   
   
   
   
   
 
   
   
 
   
   
   
   
             

- - - - - - - - HEALTH QUESTIONNAIRE DECLARATION - - - - - - - -

Signature Ilke Alp Ozer

I declare that all the information given in

this questionnaire is true and correct to
the best of my knowledge. I understand
that failure to give relevant and accurate
information may result in the Health and
Safety Advisor being unable to make any Name Ilke Alp Ozer
appropriate changes or recommendations
to workplace adjustments. Date: 24/10/2022

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