Health declaration

Personal details

1 Title Mr Mrs Miss Ms Other

2 First name(s)

3 Surname

4 Surname at birth Any other

first name(s) ever used Other
surname(s)

5 Date of birth

6 Sex Male Female

7 Current full postal address

including
postcode

8 Telephone numbers

Home or work (include area code)

Mobile

Please complete your health declaration fully. If you fail to declare

significant information about your health, we may judge that you
are not suitable to care for children and/or young people.
A
Your current state of health

1 Please give contact details of

your doctor’s surgery and any
hospitals you attend
2 Are you taking medication ? Yes No

If ‘Yes’, what is it called, what is

it for and what dose are you
taking (see box or bottle label)?

How long have you been taking

it?

3 Are you receiving any other Yes No

treatment, like physiotherapy, If ‘Yes’, what and for how long?
counselling, acupuncture?

4 Are you waiting for any other Yes No

treatment like those mentioned If ‘Yes’, please provide details.
in B3, or surgery?

5 Have you received any Yes No

treatment, like those mentioned If ‘Yes’, please provide details.
in B3, in the past five years?

6 Do you have any medical

condition that: (If you have
answered ‘yes’, please provide details
opposite) Yes No
A. Affects your physical ability
i.e. stamina, walking, balance,
bending, kneeling, lifting a child?
Yes No
B. May impair your
consciousness,
make you black out, lose
concentration or become
confused or disorientated? Yes No

C. Affects your hearing in any

way (after correction with any
hearing device)? Yes No

D. Affects your eyesight in any

way (after any lens correction)? Yes No

E. Causes depression, anxiety,

panic attacks, mood swings,
anger etc? Yes No

F. Causes severe pain? Yes No

G. Causes excessive drowsiness? Yes No

H. Affects you in any other way?

Yes No
If ‘Yes’, please provide details.
7 Have you been investigated or
treated for any of the above, in
the past five years?

8 Do you have a driving licence? Yes No

If ‘Yes’, have you ever had Yes No

restrictions put on it, or had If ‘Yes’, please provide details.
difficulty getting insurance
because of health problems

9 If you don’t have one, is that Yes No

because it was refused on health
grounds?

10 Are you in receipt of Yes No

Disability Living Allowance,
Incapacity Benefit or a medical
pension?

11 In the past five years have Yes No

you had any medical problems If ‘Yes’, please provide details.
other than minor illnesses such
as colds?

12 In the past five years have Yes No

you had any hospital admissions If ‘Yes’, please provide details.
or outpatient treatment

13 Are you suffering from or

have you ever suffered from any
of the following?
Please indicate with an asterisk
(*) any conditions that are still
current.
Yes No
(a) Depression, anxiety, stress-
related illness or other mental
health
problems, including self-harm
and eating disorders Yes No

(b) Blackouts, fits, epilepsy or Yes No

faints
Yes No
(c) Heart problems
Yes No
(d) Diabetes

(e) Breathing difficulties such as Yes No

asthma

(f) Problems with back, neck, Yes No

arms, legs or joints

(g) Alcohol or drug dependency

or misuse

If you have answered ‘yes’ to

any of the above conditions,
please provide details of any
date(s) you received treatment
and the length of time you were
on sick leave.

14 Have you ever suffered from Yes No

or been in contact with a If ‘Yes’, please provide details.
significant infectious disease, Date Details
such as tuberculosis or hepatitis?

15 What are your current weight Weight st lb

and height? or
kg
Height ft in
Or
m cm
16 Do you smoke? Yes No

17 What is your alcohol intake a

week in units? (1 unit = 1 small
glass of wine or ½ pint of beer)

18 Are you in employment? Yes No

If yes, how many days sick leave

have you taken in the last 12
months?
Yes No
Are you off sick now?

If yes, please specify how long

you’ve been off and explain the
reason why
Reason for sickness
Years Months

19 Statement of declaration and consent

Do you need my consent?

We ask for your consent to apply to your doctor, or other medical
practitioner with knowledge of your state of health, for a report
about your medical status. You do not have to give consent to such
a request. However, without consent we may not be able to
establish your mental and physical suitability to care for children
and/or young people.

We will use the information you give on this form and that given by
your GP to make a decision about your medical suitability to look
after children.

We may seek further information from your doctor or another doctor

by
telephone or in writing.

You should be aware that you will also be required to have a

medical.

I consent to North East Lincolnshire Children and Family Services

obtaining and using information about my health in the way set out
above.

I declare that to the best of my knowledge the answers given to the

questions above are full and correct.

I agree to notify North East Lincolnshire Children and Family

Services of any significant changes to my health.

For reports sent directly to NELC :

I do/do not (please delete as appropriate) wish to see a copy
of the medical report before my GP sends it to NELC.

Signed ………………………………

Print name ………………………………

Date of signature ………………………………

Explanatory note for the general practitioner

Your patient has applied to NELC to become:

a person providing childcare or social care

We have a duty to ensure that such people are suitable to look after
children and/or young people*. Part of this process is to establish
the person’s physical and mental suitability. We treat all medical
information confidentially. If necessary, we will seek further
information from other medical practitioners treating the patient or
from an independent medical examination
To help us reach a decision, you are asked to complete the section
of this form marked ‘GP verification’. Your patient has given consent
for you to do this and for us to use any information you provide to
make a decision about his or her suitability to work with children
and/or young people. Your patient understands that you may charge
a fee for this service.
Your patient can ask to see your report and that we may disclose it
to your patient in its entirety. You should note that under the Data
Protection (Subject Access Modification) (Health) Order 2000, access
to the information contained in your report can be limited or denied
where, in your opinion, it could cause serious harm to the physical
or mental health or condition of the individual or any other person,
or where access would disclose information relating to or provided
by a third person who has not consented to the disclosure. Please
indicate whether any of the information you are providing
falls within that category.
*This duty is set out in:
· the Childcare Act 2006 Section 35 (2) (b) for childminders
· the Childcare Act 2006 Section 36 (2) (b) for childcare providers
· the Care Standards Act 2000 Section 12 (2) (b) for social care providers

Notes for general practitioners on completing section C

1. Prior to completing the form please:

check section B carefully, compare the information provided

against your medical records and check that your patient has signed
the statement of declaration and consent at the end of section B 19

note if your patient has asked to see a copy of the information you
intend to submit

read your patient’s health declaration.

2. Please fully complete the GP verification form. No physical

examination is required.

NELBC requires only factual information from your patient’s records.

3. Where necessary, arrange for your patient to see the report.

4. Send the booklet back using the prepaid envelope.
5. Charge any fee you make for this service directly to NELBC.

Thank you for your help.

Should there be any change to your patient’s health that
gives cause for concern about their ability to care for
children and/or young people, or you strongly recommend in
the future that time off work is taken, please do not hesitate
to contact NELBC

GP verification form

C1. Where the health declaration

form omits significant
information, please give brief
details of the omission (please
use a separate sheet of paper if
necessary).

C2 Please provide the details of

any significant condition(s) from
which your patient is suffering,
or that
may recur, and the severity of
the condition, including: the
insight and awareness of your
patient
medical treatment (including, if
known, any paramedical
treatment) your patient receives
your patient’s compliance with
the treatment
the frequency of episodes where
appropriate if your patient has
been referred to a specialist or
has been hospitalised (please
supply the name of the
consultant and date).

Based on the information above,

what is the prognosis and what is
the likely outcome?

Is your patient likely to suffer

any complications?

C3 Please complete this table by

placing a tick in the appropriate
box to show if your patient is
affected on a functional level:

vision Yes No

hearing Yes No
lifting Yes No

mobility Yes No

carrying Yes No

bending Yes No

time off work Yes No

C4 Are you aware of any illegal Yes No

drug use or inappropriate alcohol
use by your patient?

If you have answered ‘yes’

please provide further
information (please use a
separate sheet of paper if
necessary).
C5 Please include any additional
information that will help us
reach a fair and balanced
judgement about your patient’s
ability to look after or be in
contact with children and/or
young people.

Please give details of any

significant past medical
history, including self-harm
and eating disorders

C6 Do you have your patient’s Yes No

records from birth?

Are your patient’s records for a Yes No

continuous period?

If you have answered ‘no’ please

state from what date the records
commence and/or please
give a reason, if known, for any
gaps in the records.

C7 Please provide the name and Name

address of any consultant to Address
whom your patient has been Name:
referred Postcode
(please use a separate sheet of
paper if necessary).
C8 If your patient has answered
‘Yes’ to question 12, please
comment on any condition or
medication that may have an
impact on the patient’s ability to
provide overnight care
.
C9 I confirm that the
patient’s health declaration
is a true Yes No
reflection of their health.

DDMMYYYY
Date of signature

Signed
Print name

Practice
stamp (This is mandatory
and is required to validate the
form).

Contact telephone number