Confidential

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STRICTLY CONFIDENTIAL

www.luxurycare.co.uk
“luxury care in a luxury Environment”

PRE-Employment Health Questionnaire
The purpose of this questionnaire is to determine your fitness for the post you have applied for with Luxurycare.co.uk and to advise management of any reasonable adjustments (measures needed to support you in this post if you have a disability which falls within the Disability Discrimination Act 2005). It will be retained confidentially on your Employee File in accordance with the principles of the Data Protection Act 1998. The form can also be used for those who are or have started employment with Luxurycare.co.uk. The Questionnaire consists of 2 parts, Part A which contains a Health Declaration, and Part B. N.B. Part B should only be completed if you are unable to sign the declaration in Part A. Please complete the form in black ink and CAPITAL letters.

PART A – Please complete fully.
PERSONAL DETAILS Title: Surname: Forenames: Date of birth: Address:

Day contact phone /mobile no: E mail address JOB DETAILS Proposed job title / occupation: No. of hours of work per week: Work location: Name of your Manager

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STRICTLY CONFIDENTIAL PART A continued Does the job involve the following? Please tick all that apply. Manual work Driving a company vehicle Working in a noisy environment Working with machinery/plant Working at night Working with children Working with vulnerable adults EMPLOYMENT HISTORY Are you currently employed by Luxurycare.co.uk? If so when did you commence your current post? Where are you based? What is your job title? Have you previously been employed by Luxurycare.co.uk? If so when did you leave? Where were you based? What work did you do? Yes/No Date: Handling food Lifting heavy loads Use of display screen equipment Exposure to harmful substances Working at times in a confined space Performing emergency procedures Performing fire drill

Yes/No Date:

Please sign and date below if this declaration is applicable to you:

DECLARATION
I declare that I am fit and well and have NO physical or mental health conditions at present and have not had ANY physical or mental health conditions or any disability or condition which has had an effect on my day to day life in the past 12 months. Signed…………………………………………………………………………………………………… Dated………………………………………………………………………………………………………

PLEASE STOP HERE if you have signed the above declaration. You can now throw away Part B and RETURN PART A ONLY to the Care Home Manager. N.B. If you have health conditions and cannot sign the above declaration, please continue and complete Part B and the Consent Form, and then send ALL PARTS OF THIS FORM to your Manager.

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STRICTLY CONFIDENTIAL

PART B
HEALTH HISTORY Your height ……………………………. Your weight …………………………… Yes/No Yes/No Yes/No Yes/No

Are you enjoying good health at the moment? Do you have a hearing problem not corrected by a hearing aid? Do you have a sight problem not corrected by spectacles/contact lenses? Do you have a speech problem? if yes please give details below How many days sickness have you had in the 12 months? How many episodes of sickness does this represent? Reasons for the sickness ………………………..……………………..…………………. …………………………………………………………………………………………………

Have you claimed Incapacity Benefit or been granted Ill Health Retirement? Yes/No Please give details ….……………………………………………………………………… ………………………………………………………………………………………………… Do you have, or have you had any of the following in the past 12 months? Please give full information in the details column Please specify condition and give details 1. Allergies or sensitivity to any substance 2. Asthma or hayfever 3. Skin problems e.g. eczema, psoriasis, dermatitis 4. Back, neck, wrist or other joint problems affecting mobility or function 5. Arthritis or rheumatism 6. Chest pain 7. Bronchitis or pneumonia 8. Heart problem or angina 9. High blood pressure 10. Stroke Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No...
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