Welcome House Residential Care Homes

WELCOME HOUSE RESIDENTIAL CARE HOMES

IN CONFIDENCE

MEDICAL QUESTIONNAIRE

Please complete this form in black ink or typescript

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