MEDICAL QUESTIONNAIRE
Personal Details To be completed by employee
Surname Address
Forname
DOB
Postcode
Tel No
Name/Address of GP Tel No
Medical History (Do you have, or have you had in the past, any of the following conditions?)
Conditions of the lungs? Asthma? Bronchitis? Yes Details
Pleurisy, Tuberculosis? Other chest complaints? No
Coughing up blood? Shortness of breath?
Conditions of the ears, nose and throat? Sinus Yes Details
trouble? Frequent colds & sore throats? Ear
infections? Hearing deficiency? No
Any heart condition? Rheumatic feaver? Shortness of Yes Details
breath? High blood pressure? Heart attacks? Poor No
circulation? Chest pain on exertion?
Blood disorders? Anaemia? Unexpected bruising? Yes Details
No
Nervous system diseases? Blackouts? Epilepsy? Yes Details
Muscular weakness? Headaches? Paralysis? Loss No
of sensation? Tingling or numbness of limbs?
Conditions of the digestive system? Indigestion? Yes Details
Abdominal pain? Gastro/duodenal ulcer? No
Constipation? Diarrhoea? Bleeding from the stomach
or bowel? Liver complaints/Jaundice?
Conditions of the kidneys or bladder? Urinary Yes Details
infections? Blood in the urine? Kidney stones? No
Any sexually transmitted diseases? Are there any Yes Details
factors which place you at risk of infection by the No
AIDS virus?
Conditions of the bones & joints? Arthiritis? Yes Details
Rheumatism? Backache or pains? Sciatica? Strains No
& sprains? Repetitive strain injuries (eg. Tennis elbow,
tenosynovitis)?
Hayfever or allergic conditions (including allergies Yes Details
to drugs)? No
Skin conditions? (ie. Exzema, porisis, etc) Yes Details
No
Anxiety/depression, mental breakdown or stress Yes Details
related problems? Or any other mental illness? No
Have you ever been medically dischaged from the Yes Details
Armed Forces/Police Force/previous employer? No
Employee's Signature
The information I have provided is accurate an I have not withheld any details. I understand that the giving of false information
or withholding information could subsequently result in my dismissal. I will notify you if any of my answers change.
Signed Name Date
Doctor's Signature
I confirm that I have seen/have not seen the patients medical notes and that the above information is true to the best of
my knowledge. (delete as appropriate)
Signed Name Date
1
MEDICAL QUESTIONNAIRE
To be completed by Doctor
Date of examination Name of Doctor
Height Ideal weight actual weight
B.P. P.R. P.E.F
Urine Hands Feet
Ears L Eyes R Near Far
Ears R Eyes L Near Far
Lenses/Glasses Yes/No Eye colour
Throat Mouth
Lungs Heart
Abdomen Circulation
Breasts Lymph Nodes
Vitalograph
Skin
Neck
Back
Joints
Spine
Tone Power Reflexes
Sensation Coordination Balance
Scars/Deformities
General Appearance
Have you seen this persons full medical notes? Yes/No
How long has this person been been your patient? Yrs Months
Any other comments:
After full examination I find this person to be fully fit.
Signed Name Date
Surgery Stamp:
Should you have any queries regarding this document please do not hesitate to contact Armor
Group Welfare Coordinator on +44(0)20 7808 5887 or [email protected]
