Brain Injury Care Provider

Pre-employment Health Questionnaire

The purpose of this form is to ensure that, as far as possible, you are fit to undertake your duties in the NHS and UK private health sector and to protect your own health and the health of those around you. The information you give will remain confidential, except for immunisiations which will be shared with the NHS or any other health provider you wish to work for.    

If you have any difficulties completing this questionnaire, please contact your consultant.

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1. Your contact details

2. Details of your GP?

3. Please answer all the following questions:

4. Please answer the following questions about any immunizations and blood tests you have had. Please provide original certificates that verify your answer. If you answer YES, please give details in the space provided or continue on the back page.

* Information for these items is mandatory

* Information for these items is mandatory if you are intending to work with Exposure-Prone Procedures

* Information for these items is mandatory

* Information for these items is mandatory

* Information for these items is mandatory

5. Declaration

I understand that Healthcare workers are under ethical and legal duties to protect the health and safety of their patients, their colleagues and themselves as laid down in their Codes of Professional Conduct.  I have been reminded that it is unethical for Healthcare workers who know that they are infected, or believe themselves to be infected, with any blood borne viruses (HIV, Hepatitis B or C) or with other modifiable diseases (e.g. Tuberculosis) to put patients at risk by failing to seek appropriate counselling or by failing to act upon that counselling when given. Completing this health questionnaire honestly is part of this responsibility. With this mind I confirm that all the information provided on this form is correct and accurate to the best of my knowledge.

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Call us today!

For a free, no-obligation discussion about our UK complex care in the home for brain injury, spinal cord injury, long-term ventilation, cerebral palsy, multiple sclerosis, muscular dystrophy and other neurological conditions, please click here or call 024 7610 2333.