Medical Form - Permanent Recruitment Solutions

Name*

Have you any difficulties with standing/walking/lifting or use of hands?*

If Yes, please provide details

Have you ever been denied a job through health grounds?*

If Yes, please provide details

Do you take any medication?*

If Yes, please provide details

Do you have any visual defect or difficulty which is not corrected by glasses or contact lenses?*

If Yes, please provide details

Do you have any hearing difficulties or tinnitus?*

If Yes, please provide details

Do you have a lung condition, e.g. Asthma, Tuberculosis, undiagnosed shortness of breath?*

If Yes, please provide details

Do you have heart or circulation conditions such as angina, palpitations, high blood pressure?*

If Yes, please provide details

Do you have any allergies?*

if Yes, please list allergies

If Yes, what symptoms do you suffer from?

Do you carry an epipen?

If Yes, please indicate the severity of your allergy.

Have you been in contact with anyone within the last 14 days that you know or suspect has COVID-19?*

Do you currently have a new persistent cough*

Do you currently have a fever or temperature above 38°C*

Do you currently have a loss of taste or smell*

At present, or in the last seven days, are you, or have you been, suffering from diarrhoea and/or vomiting?*

If Yes, has it been 48 hrs since your last symptoms?

At present, or in the last seven days, are you, or have you been, suffering from stomach pain, nausea or fever?*

At present, are you suffering from any skin infections of the hands, arms or face, i.e.: boils, styes, septic fingers, discharge from eye / ear / gums mouth?*

If Yes, please provide details

Please detail any other health conditions that we need to be aware of

Please list any countries you have visited in the last 6 weeks