Medical Questionnaire – Acorn – Oakmans Forms

Medical Questionnaire – Acorn

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– Step 1 of 4

Name *

First

Last

Date of Birth *

Doctor's Name *

Doctor's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

How Many Days Absence Have You Had Due to Sickness or Injury in the Last 12 Months? *

Do not include sickness due to pregnancy.

Are You In Good Health? *

Yes
No

Please Give Full Details *

Is Your Hearing Good? *

Yes
No

Please Give Full Details *

Is Your Eyesight Good? *

Yes
No

Please Give Full Details *

Do You Consult An Optician? *

Yes
No

Please Give Full Details *

Do You Have a Speech Disorder? *

Yes
No

Please Give Full Details *

Full Do One

Have You Any Disability That Could Be Classed as a Disability Under the Equality Act 2010? *

Yes
No

Please Give Full Details *

Have You At Any Time Suffered From Any of The Following:

Headaches/Migraines/Blackouts/Epilepsy/Mental or Nervous Disorders/Anxiety or Depression? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Have You Ever Seen a Psychiatrist or Had an Emotional or Psychological Disorder? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Tuberculosis/Asthma/Pneumonia/Bronchitis/Pleurisy/Persistent Cough/Or Any Other Disease of the Lungs? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Any Heart Trouble/High Blood Pressure/Palpitations/Fainting/Rheumatic Fever? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Diabetes/Kidney Disease/Bladder or Urinary Trouble? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Rheumatism/Arthritis? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Back Trouble/Lumbago/Sciatica? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Haemophilia or Any Blood Disorders? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Any Other Condition Needing Hospital Attendance, Serious Injury, Operation or Sickness Absence for More Than One Month. *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Are You Awaiting Hospital Admission for Tests or Any Other Reason? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Are You Currently Receiving Medical Treatment Under Observation or Undergoing Medical Tests? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Are You Currently Taking Any Pills or Medication for Any Other Reason? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Have You Ever Had any Difficulty in Using VDU or Other Keyboard/Screen Based Equipment, and, If So, Has This Resulted in Problems for Which You Have Needed Medical Advice or Treatment? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Have You Ever Left Employment on the Grounds of Ill Health? *

Yes
No

Please Give Full Details *

Please provide full details of illness, treatment and medication taken currently or in the past. Please provide dates where appropriate.

Employee Declaration

I declare that to the best of my knowledge and belief that the particulars given are true and correct and that I have not withheld any information or material fact. (Please note that any deliberate attempt at concealment of material evidence may potentially be grounds for dismissal at a later date).

I confirm that by signing this form I have agreed to consent to referral to a medically qualified person should the organisation deem it necessary, and give my permission for any medical or sickness record to be held, in confidence, by the organisation. If the company requires you to undergo a medical examination or provide authority for medical reports to be sought from doctors who have attended you, you will be advised separately.

Data Protection

For the purposes of compliance with the Data Protection Act 1998, I hereby give my consent to the organisation processing the data supplied in this questionnaire.

Signature *

Clear Signature

Full Name *

Date *