Health Declaration Form For candidates to submit their health declaration form online. Health Declaration - Confidential Please complete this form accurately and honestly. Name First Last Date Form Completed:* DD slash MM slash YYYY Gender*MaleFemaleOtherPlease select your gender.Your Date of Birth:* DD slash MM slash YYYY Role Applied:*Homecare Worker - Care in the CommunityHealthcare Assistant - Hospital or PrivateOtherPlease select which role you have applied for.1. Do you have, or have you ever had, any medical conditions or operations?* Yes No Please provide detail:*2. Are you receiving any pills/tablets, injections, or other treatment, at the moment? (including pills, tablets, inhalers, injections, self-medication, physiotherapy, psychotherapy etc)* Yes No Please provide detail - including any medication you are taking and the prescribed dose:*3. Have you ever suffered a work-related illness, or given up work because of ill health?* Yes No Please provide detail:*4. Have you ever had any physical limitation? (including vision or hearing)* Yes No Please provide detail:*4.1 Has there been /might there be an effect on your ability to work?* Yes No Please provide detail:*5. Have you ever had any kind of back, joint or muscle problem?* Yes No If yes, did it lead to time off work?*6. Have you ever had any mental illness? (including anxiety, depression, self-harm, eating disorders, psychological or emotional problems)* Yes No Please provide detail:*6.1 Has there been /might there be an effect on your ability to work?* Yes No Please provide detail:*7. Have you ever had a drug or alcohol problem?* Yes No Please provide detail:*7.1 Has there been /might there be an effect on your ability to work?* Yes No Please provide detail:*Have you ever had, or do you currently have any problems with the following? You may have already entered some of this information above - If you answer yes to any of the below, please provide some brief information. 8. A mental health condition that required/requires hospital treatment and/or drug treatment (e.g. Depression, Anxiety, Schizophrenia, Bipolar,)* Yes No Please provide detail:*9. A chest complaint, breathing, pain, or condition requiring hospital treatment, surgery or drug treatment (e.g. TB, Cancer, Asthma, Heart condition, High Blood pressure)* Yes No Please provide detail:*10. Migraines, Epilepsy, Blackouts, or Vertigo - requiring hospital treatment and or drug treatment (e.g. Fits, headaches, dizziness/neck pain)* Yes No Please provide detail:*11. Back Pain or Arthritis/Spinal Problems/Muscular - requiring hospital treatment and or drug treatment (e.g. Rheumatoid Arthritis/Osteoarthritis)* Yes No Please provide detail:*12. Eyesight or Hearing Problems (e.g. Do you wear glasses or hearing aids)* Yes No Please provide detail:*13. Stomach, Kidney or Bowel condition requiring hospital treatment or drug treatment (e.g. Colitis, Pancreatitis, IBS Diverticular disease, Cancer, Gall bladder problem, Hernia)* Yes No Please provide detail:*14. Diabetes, thyroid or glandular conditions requiring hospital treatment and or drug treatment* Yes No Please provide detail:*15. Allergies/Skin disorders requiring treatment (for e.g. Skin diseases, Psoriasis, Eczema, MRSA)* Yes No Please provide detail:*16. Infectious/Contagious diseases requiring any kind of treatment (for e.g. Diarrhoea, HIV Aids)* Yes No Please provide detail:*17. Do you have any health issues not covered by this form you would like to inform us of:* Yes No Please provide detail:*18. Have you had surgery in hospital in the past 2 years?* Yes No Please provide detail:*19. Are you a hospital outpatient receiving treatment?* Yes No Please provide detail:*20. How many days have you taken in sick leave in the past 2 years?* 14. Have you been vaccinated for any of the following:Tuberculosis/ BCG:* Yes No COVID 19 Vaccine:* Yes No 1st COVID-19 Vaccine Date:* DD slash MM slash YYYY 2nd COVID-19 Vaccine Date: DD slash MM slash YYYY COVID 19 Booster Date: DD slash MM slash YYYY Vaccination Card Drop files here or Select files Max. file size: 80 MB. Please take a photo and upload your vaccine cards here.Varicella:* Yes No Have you ever had chicken pox?* Yes No MMR (Measles, Mumps and Rubella):* Yes No Tetanus: inclusive of (Dip/Tet/Polio x 5:* Yes No Hepatitis B:* Yes No It is your responsibility to inform your Manager immediately if any of the above changes.Certify* I certify that the information I have provided is accurate and that I am in good health and fit to carry out the duties as described in the job description in relation to the role I am applying for.Signature*Please either draw your signature in the box above or use your finger or stylus if on a touchscreen device. TO BE COMPLETED BY GP Does the candidate have a BCG scar providing evidence of receiving their BCG vaccination. YES NO Has the candidate been administered the required vaccinations based on their submitted vaccination record to work on NHS/Hospital sites. YES NO In my professional opinion based on the information provided I declare the above-named candidate fit to work as a provider of health care in the capacity as a healthcare assistant. YES NO Doctor’s Signature: Doctor’s/ Clinic Stamp Print Name: Date:
