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

Your name*

Best contact number

Email address*

Date of Birth

Job title

Gender

Male

Female

Will your work involve Exposure-Prone Procedures?

Yes

Preferred time to contact you if any follow up is needed

2. Details of your GP?

Name of GP*

Street*

Country*

Surgery name*

City*

Postcode*

Telephone*

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.

Signed*

Enter name

Date*

This field should be left blank