Welcome House Residential Care Homes

WELCOME HOUSE RESIDENTIAL CARE HOMES IN CONFIDENCE MEDICAL QUESTIONNAIRE Please complete this form in black ink or typescript

Please complete the questionnaire below. The information is required with your interests in mind. As a result of the information you have given you may be referred to a doctor appointed by the company so that a medical examination can be carried out.

HAVE YOU EVER: NO YES PLEASE GIVE DETAILS Had an operation?

Been Seriously injured?

Received treatment for a physical or mental condition? Been refused or dismissed from employment for health reasons? Received a disability pension?

Been registered disabled?

Been made ill by your work?

Been refused a drivers licence because of ill health?

DO YOU SUFFER FROM OR HAVE YOU EVER HAD ANY OF THE FOLLOWING: Anaemia Yes No Epilepsy/Fits Yes No Nerve Trouble Yes No Arthritis Yes No Eye Trouble Yes No Period or Prostate Problems Yes No Asthma Yes No Fainting or Dizziness Yes No Rheumatic Fever Yes No Back Trouble Yes No Hay Fever Yes No Rupture Yes No Chest Trouble Yes No Headaches (Frequent) Yes No Shortness of Breath Yes No Cough (Frequent) Yes No Heart Trouble Yes No Skin Rashes/Eczema Yes No Diabetes Yes No High Blood Pressure Yes No Swelling of Legs/Ankles Yes No Ear Trouble Yes No Jaundice Yes No Varicose Veins Yes No

Do you take medication Do you need glasses Have you worked in a Have you ever had a Do you suffer regularly? to read? dusty trade? head injury? from any other Yes/No Yes/No Yes/No Yes/No ailments? Yes/No

If you have answered yes to any of the above questions please provide further details in the space below and continue overleaf if necessary.

To the best of my knowledge and belief the information I have given on this form is correct and I know of no reasons, physical or mental, that would prevent me from understanding the duties of the post applied for. I understand that if I am appointed and this information is inaccurate, I am liable to dismissal. Name: Date of Birth: Signature: Date:

Ref: Medical Questionnaire_05092005 September 2005 Page 1 of 1