Health Survey | ICP LTD

First name

Last name

HEALTH QUESTIONS:

Do you have any physical or mental impairment that could be classed as a disability under the Equality Act 2010?

Yes

No

Unsure

Have you ever received compensation or a disability pension?

Yes

No

Unsure

Are there any medical reasons why you should not do shift work?

Yes

No

Unsure

Are you able to carry out physical work to complete you job role which may include climbing ladders, working from scaffolding, bending, lifting and carrying?

Yes

No

Unsure

Have you ever had to give up any previous job for medical reasons?

Yes

No

Have you been off work continuously for more than a month during the last five years?

Yes

No

Have you ever had any operations requiring hospital admission for five or more days?

Yes

No

Is your eyesight normal (with glasses if worn)?

Yes

No

Is your hearing normal?

Yes

No

Do you regularly take tablets or medicine?

Yes

No

If yes, what do you take?

Have you ever had any of the following during the last 5 years??

Bronchitis, asthma, pneumonia

Dermatitis, eczema or any other skin trouble

None

Do you suffer from any of the following? (Please select all that are applicable)

Migraine or severe recurring headaches

Anxiety, depression or any other nervous complaint

Fainting attacks or giddiness

Ear trouble, discharging or infected ear

Kidney trouble or urinary infection

None

If you have selected any answers from the previous 3 questions, please give very brief details below:

Have you ever had any other serious illness?

Yes

No

If yes, please give very brief details below:

Have you consulted a doctor about your health during the last 12 months?

Yes

No

If yes, please give very brief details below:

I am willing to undergo a medical examination if required and I declare that the information I have given on this form is correct to the best of my knowledge.

The organisation treats personal data collected in this medical questionnaire in accordance with its privacy policy. To view the policy, visit: www.icp-ltd.com/privacy

PRECISION. QUALITY. EXPERIENCE.

ICP SUBCONTRACTOR HEALTH SURVEY

enquiries@icp-ltd.com

0121 516 3259

ACCREDITATIONS: