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:* Date Format: DD slash MM slash YYYY Gender*MaleFemaleOtherPlease select your gender.Your Date of Birth:* Date Format: DD slash MM slash YYYY Have you ever had, or do you currently have any problems with the following? If you answer yes to any of the below, please provide some brief information. 1. A mental health condition that required/requires hospital treatment and/or drug treatment (e.g. Depression, Anxiety, Schizophrenia, Bipolar, Alcoholism)* Yes No Please provide detail:*2. 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:*3. Migraines, Epilepsy, Blackouts, or Vertigo - requiring hospital treatment and or drug treatment (e.g. Fits, headaches, dizziness/neck pain)* Yes No Please provide detail:*4. Back Pain or Arthritis/Spinal Problems/Muscular - requiring hospital treatment and or drug treatment (e.g. Rheumatoid Arthritis/Osteoarthritis)* Yes No Please provide detail:*5. Eyesight or Hearing Problems (e.g. Do you wear glasses or hearing aids)* Yes No Please provide detail:*6. 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:*7. Diabetes, thyroid or glandular conditions requiring hospital treatment and or drug treatment* Yes No Please provide detail:*8. Allergies/Skin disorders requiring treatment (for e.g. Skin diseases, Psoriasis, Eczema, MRSA)* Yes No Please provide detail:*9. Infectious/Contagious diseases requiring any kind of treatment (for e.g. Diarrhoea, HIV Aids)* Yes No Please provide detail:*10. Do you have any health issues not covered by this form you would like to inform us of:* Yes No Please provide detail:*11. Have you had surgery in hospital in the past 2 years?* Yes No Please provide detail:*12. Are you a hospital outpatient receiving treatment?* Yes No Please provide detail:*13. 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 Varicella:* 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 Homecare 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.
