If your answer is yes to any of the following, please give full details in the space provided, using additional sheets if necessary.
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| Do you have, or are you being treated for, a medical condition? | | |
| Have you suffered from any medical conditions in the past that may reoccur? | | |
| Do you need any special aids or adaptations to assist you at work, whether or not you have a disability? | | |
| Do you have, or have you ever suffered from, and musculo-skeletal condiditions? For example, back, joints, tendons or ligament problems. | | |
| Do you have, or have you ever suffered from, any psychiatric or stress related conditions? | | |
| Are you currently on prescribed medication? | | |
| Are you currently receiving, or waiting for, any medical treatment? | | |
| Have you consulted a doctor in the past year? | | |
| Have you undergone any surgery or have you been a hosital in-patient over the past two years? | | |
| Have you ever suffered from any medical condition you consider to have been caused by work? | | |
| Do you have any medical condition or disability that you feel will affect your ability to perform this role? | | |
| Have you ever left or been denied a job due to medical reasons? | | |
| Have you been absent from work due to illness over the past two years? If so please give details of total days, number of occasions and reasons. | | |
| Do you drink alcohol? (If yes, units per week) One unit = 1/2 pint of beer, 1 glass of wine or 1 pub measure of spirits. | | |
| Do you smoke? (If yes, amount per day) | | |
| Have you ever been treated for alcohol or drug related problems or been advised to reduce your alcohol intake? | | |
| Additional information (please advise of any additional information related to information related to your health that may be relevant to your ability to carry out your role safely). | |