Pre-Employment Medical Questionnaire

Welcome to our new website!

Cafe/Site you are sending to:

Contact Telephone Number

We will not contact your doctor without your prior written consent.

How many days absence have you had from work in the last three years?

How many periods of absence have you had in last three years?

Are you currently taking or have been prescribed medication (excluding contraceptives)?

Yes No

Please give further details.

Are you currently receiving treatment for any physical or mental condition?

Yes No

Please give further details.

Do you suffer from any injury, illness, medical condition or allergy that might affect your ability to perform your duties?

Yes No

Please give further details.

Do you consider yourself to have a disability?

Yes No

Please give further details.

DATA PROTECTION NOTICE

The Company requires certain information before you start employment, to ensure you will be able to perform the requirements of the job and give reliable service and to ensure compliance with relevant Health and Safety regulations. The information is also required in order to establish whether any reasonable adjustments may need to be made to assist you in performing your duties, in accordance with the Equality Act 2010.

The information you provide will be treated in the strictest confidence, and used only for the purposes detailed above in compliance with current Data Protection Legislation.

DECLARATION

I confirm that the information given in this questionnaire is complete and accurate to the best of my knowledge.

Yes No

THE VENUS COMPANY
Unit A, Block B
Halwell Business Park
Halwell, Nr Totnes
TQ9 7LQ
+44(0)1803 712648

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PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE FORM

DATA PROTECTION NOTICE

DECLARATION

THIS SITE USES COOKIES.