healthform - WH Bond & Sons Ltd

Annual Medical Questionnaire 2023

Annual Medical Questionnaire 2023

Please complete the following questionnaire. Please complete the ‘Further Information’ section if you answer No to Question 1 and Yes to Questions 2-21. When you declare ‘NO’ to any of the following you are accepting a degree of responsibility for your health. Please study this list and select the appropriate box. You MUST sign the declaration.

Your Full Name

1. Do you believe yourself to be in a good state of health? Mentally and physically?

Further information

2. Do you suffer from asthma attacks?

Further information

3. Do you have any allergies?

Further information

4. Do you have any illnesses or conditions that would prevent you from carrying out your duties such as a Musculoskeletal disorder?

Further information

5. Do you have Diabetes requiring Insulin?

Further information

6. Do you suffer from Epilepsy or Fits?

Further information please include type and last attack:

7. Have you ever had blackouts, recurrent dizziness or any condition which may cause sudden collapse or incapacity?

Further information

8. Do you get discomfort or chest pain/shortness of breath on moderate exercise? e.g., climbing a short flight of stairs.

Further information

9. Do you have difficulty in moving quickly over short distances, including slopes, steps or rough ground?

Further information

10. Would you have difficulty in looking over either shoulder?

Further Information

Further information

11. Do you have difficulty with your eyesight? (Simple problems corrected by glasses are excluded)

Further information

12. Do you have a family history of hearing disorders?

Further information

13. Do you have difficulty hearing normal conversations?

Further information

14. Do you have any medical disorder that can affect the use of hearing protection such as – earache, irritation of the ear canal, discharge, hearing loss, or any type of ear disease or skin disorder?

Further information

15. Are you taking any medication that is, or may, cause dizziness or drowsiness?

Further information

16. Do you have any numbness or tingling of the fingers lasting more than 20mins after using vibrating equipment?

Further information

17. Do you have difficulty picking up very small objects, eg screws or buttons or opening tight jars?

Further information

18. Do you have numbness or tingling of the fingers at any other time?

Further information

19. Do you wake at night with pain, tingling, or numbness in your hand or wrist?

Further information

20. Have any of your fingers displayed a clear white discoloration on cold exposure?

Further information

21. Do you suffer blistering, redness, dry cracked skin around the hands - Dermatitis

21. Do you suffer blistering, redness, dry cracked skin around the hands - Dermatitis?

Further information

Please write your name in the box to confirm the information provided in this questionnaire is correct. Please click 'Submit' Once done

Thank you for completing the annual medical questionnaire. These details will be kept securely electronically by WH Bond & Sons for your employment and at least 40 years from the date of your last questionnaire entry, as required by the Health and Safety Executive.
Your Manager may come back to you if further action is required.
If you wish to take a copy of your health record when you leave WH Bond & Sons please contact the office.
Your Doctor will not be contacted without your prior written consent to do so
All information disclosed will be treated in the strictest confidence and will only be used for the purposes detailed in the Data Protection Act 2018.

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