New Employee Medical Information Form

As an Employee of Kernock Park Plants, we require you to submit these medical details to us. As an Employee of Kernock Park Plants, we require you to submit these medical details to us.

Personal Details (To be given to a Doctor in the event of an emergency) Personal Details (To be given to a Doctor in the event of an emergency)

Title

First & Last Name

Home Address

Town

Post Code

Home Tel. No.

Mobile Tel. No.

Medical History Medical History

This questionnaire is designed to help the Company meet its legal Health and Safety duties, assess whether there are any existing health issues likely to affect your employment and to find out if any changes need to be made to the workplace under the Disability Discrimination Act 1995. The information that you would provide helps your employer to make sure that they are not putting yourself or other employees at risk. The information supplied will remain strictly confidential and can be accessed only by authorised personnel. No information will be given outside of the company. Our aim is to promote and maintain the health of all people at work This questionnaire is designed to help the Company meet its legal Health and Safety duties, assess whether there are any existing health issues likely to affect your employment and to find out if any changes need to be made to the workplace under the Disability Discrimination Act 1995. The information that you would provide helps your employer to make sure that they are not putting yourself or other employees at risk. The information supplied will remain strictly confidential and can be accessed only by authorised personnel. No information will be given outside of the company. Our aim is to promote and maintain the health of all people at work

1. Are you taking any prescribed Medicine? 1. Are you taking any prescribed Medicine? Yes No

2. Are you currently under the care of a doctor or other medical professional? 2. Are you currently under the care of a doctor or other medical professional? Yes No

3. Do You Smoke? 3. Do You Smoke? Yes No

4. Are you currently suffering from, or have suffered from any of the illnesses listed below? (Tick Where Relevent) 4. Are you currently suffering from, or have suffered from any of the illnesses listed below? (Tick Where Relevent) Heart Trouble Lung Disease Stomach/Bowel Trouble Jaundice/Hepatitis Headaches/Migraines Diabetes Allergies Severe Stress Reaction Injury From Serious Accident High Blood Pressure Asthma Hernia/Rupture Kidney/Bladder Disorder Back/Neck Problems Fits/Blackouts/Epilepsy Depression/Anxiety Hearing/Sight Problems Skin Problems Injury From Surgical Operation Mobility Problems None of The Above/No Medical Issues

If you have answered "yes" to any of the questions, please give details and approximate dates where relevant. This is particularly important where you have a qualifying disability under the Disability Discrimination Act 1995, as it will enable us to identify what, if any "reasonable adjustments" can be made. If you have answered "yes" to any of the questions, please give details and approximate dates where relevant. This is particularly important where you have a qualifying disability under the Disability Discrimination Act 1995, as it will enable us to identify what, if any "reasonable adjustments" can be made.

We recommend that you have ensured you are up to-date with your tetanus vaccinations We recommend that you have ensured you are up to-date with your tetanus vaccinations

Please Enter Comments Here

Next Of Kin Details Next Of Kin Details

First & Last Name

Relationship

Their Address

Town

Post Code

Home Tel. No.

Alternative Tel. No.

Their E-Mail address

Declarations Declarations

I hereby declare that the information given is full and true to the best of my knowledge. I understand that if, later, it is discovered that I have knowingly withheld medical information, disciplinary action may be taken against me, which may include dismissal. I hereby declare that the information given is full and true to the best of my knowledge. I understand that if, later, it is discovered that I have knowingly withheld medical information, disciplinary action may be taken against me, which may include dismissal.

I agree to the above statement (Please Tick) I agree to the above statement (Please Tick) yes