Title
Name
Gender
Date of Birth
Personal email
Employee mobile number
Home address

In case of emergency we should notify

Name
Relationship to you
Contact Number

GP Details

Name of GP
Address
Contact Number

Medical Questionnaire

Present Health Status	Yes	No	If yes, please give details
Do you have any health problems which restrict your activities of daily living?
Do you suffer with any allergies (e.g., hay fever, food products, chemicals or medication)?
Do you have any dietary restrictions, preferences, or food allergies we should be aware of for catering purposes during our monthly meetings (e.g., vegan, vegetarian, gluten-free, celiac, lactose intolerance, halal, kosher, etc.) If your preference changes, please let us know so your choice can be catered for.
Do you suffer from any condition that requires regular medical review or time away from work for treatment or rest?
Do you suffer from any condition that may cause drowsiness or impair your concentration?
Has your doctor advised you against taking any employment because it may put you at risk?
Are you a current smoker or ex-smoker?			Cigarettes per day:
Do you consume alcohol?			Units per week:
Are you currently taking any prescription medication?			Type:
Are you currently taking any non-prescription medication or remedies?			Type:
Do you have any other relevant health problems?

Medical History

Have you ever had, or do you currently suffer from:	Yes	No	If yes, please give details
Heart Disease, Heart Attack, Stroke, Heart Palpitations
Varicose Veins, Blocked Arteries, Clots, Blood Disorder
Hernia
Blackouts, Fits, Fainting, Epilepsy, Spasms, Dizziness, Giddiness, Vertigo
Persistent or severe headaches or migraines
Head injury, Brain injury, Concussion
Back pain, Neck pain
Visual impairments/Eye conditions
Arthritis, Rheumatism, Other joint issues
Hepatitis, Jaundice
Stomach Ulcers, Indigestion, Pancreatitis, Bowel problems, or any other abdominal disorders
Kidney problems, overactive or underactive thyroid gland, Bladder problems
Nervous disorder, Claustrophobia, Depression, Anxiety, or any other stress related disorders
Eczema, Psoriasis, Dermatitis, other skin disorders
High blood pressure
Diabetes, High cholesterol
Undergone a sergical operation or been admitted to hospital for any reason
Any other medical condition not alread listed

We're committed to supporting all individuals, including those who may identify as neurodiverse. If you identify as neurodiverse, or if any specific adjustements would improve your experience, please let us know so we can offer tailored support.

I declare that the answers and information given in this questionnaire are true and correct to the best of my knowledge and I have not willingly omitted any information.

Signature

Print Name
Date

Payroll Details

Start Date
NI Number

Do you have other paid employment?	Yes	No

Company Name
Hours

Bank Details

Name on Bank Account
Name of Bank
Account Number
Sort Code

Do you have a P45?	Yes	No

Signature

Date