Employment – Health Declaration / Uncategorised / By Matthew EHCS Please enable JavaScript in your browser to complete this form. – Step 1 of 4HEALTH – CONDITIONS Have you suffered from any of the following in the last 3 years?Tuberculosis, asthma, bronchitis, or any disease of the lungs *YesNoIf yes Please provide details below Additional Comments Heart disease or disorder, strokes, or high blood pressure *YesNoAdditional Comments Rheumatic or disease Rheumatic Fever *YesNoAdditional CommentsOsteoarthritis, Rheumatoid Arthritis, or other painful inflammatory conditions *YesNoAdditional CommentsBack trouble i.e., slipped disc, lumbago or other mobility difficultiesYesNoAdditional Comments Any neurological disorders e.g., Multiple Sclerosis or Epilepsy *YesNoAdditional Comments Diabetes: Type 1 or 2 *YesNoAdditional CommentsSkin disease e.g., eczema or dermatitis *YesNoAdditional Comments Any known allergies *YesNoAdditional Comments Recurrent stomach troubles, gastric disorders/vomiting *YesNoAdditional Comments A hernia *YesNoAdditional CommentsAny hearing defects/difficulties in either ear *YesNoAdditional CommentsEye disease (including Colour blindness), visual difficulties *YesNoAdditional CommentsMental health complaints e.g., depression, Post-Traumatic Stress Disorder *YesNoAdditional CommentsPlease tell us any other health information that you think is important for us to know. NextHEALTH DECLARATION – MEDICAL PROCEDURES, APPOINTMENTS AND DIAGNOSESIn additional have you Had within the last 12 months or are awaiting any surgical operations or hospital appointments *YesNoAdditional CommentsReceived medical treatment during the past three months or awaiting treatment *YesNoAdditional Comments Received any immunisation or vaccines in the last twelve months *YesNoAdditional CommentsBeen diagnosed with any contagious illness or disease during the last twelve months *YesNoAdditional Comments Please tell us any other treatment or diagnosis information that you think is important for us to know. NextIMMUNISATION Please declare any vaccinations that you have had that are relevant to working in health and social careVACCINATION DATE COMMENTSVACCINATION DATE COMMENTS VACCINATIONDATE COMMENTS VACCINATION DATE COMMENTS VACCINATIONDATE COMMENTS VACCINATIONDATE COMMENTS NextAPPLICANT DECLARATION I agree to a medical examination or report, or to respond to a request for further medical information, if I am offered work by Essential Homecare Services, if deemed necessary. *YesNoI authorise Essential Homecare Services to contact my own doctor or any other consultant or specialist to whom I have been referred. *YesNoI acknowledge that any information gathered by Essential Homecare Services as a result may be used to determine what adjustments, if any, might need to be made to allow me to safely perform my duties. *YesNoI certify that I have answered the questions truly and fully and that I am not aware of any other health reason which will, or may, affect my working capacity. *YesNoI understand and agree to a Staff Risk Assessment being completed, in relation to my health, should this be appropriate to my working role. *YesNoI understand that my Health Declaration will be kept a Staff Health File which is only accessible by senior management. *YesNoName *FirstLastSignature * Clear Signature Date / Time *Submit
