the HUB
Leave Request
Time Sheet
Driver CPC
Tachomaster
Medical Questionnaire
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Before you start..
This questionnaire must be completed for all driving positions. You will need your GP, medication and any sickness absence details to hand.
1. Personal Details
Name
*
First
Middle
Last
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
*
Email
Confirm Email
2. General Practitioner's Details
Name
Telephone Number
Address
Equality Act 2010
Do you have a disability which may affect your ability to undertake the role or which requires special arrangements?
*
Yes
No
The Equality Act 2010 defines a person with a disability as “A physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.” If yes, what facilities/adjustments/equipment might enable you to perform the role?
4. Medical Conditions
4.1 Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness?
*
Yes
No
4.1 If answered yes, please give details.
4.2 Vertigo, dizziness, giddiness, problems with balance?
*
Yes
No
4.2 If answered yes, please give details.
4.3 Recurrent headache or migraine?
*
Yes
No
4.3 If answered yes, please give details.
4.4 Diseases of the nervous system e.g. neuritis, stroke, multiple sclerosis?
*
Yes
No
4.4 If answered yes, please give details.
4.5 Chest pain, angina, heart disease or breathlessness?
*
Yes
No
4.5 If answered yes, please give details.
4.6 Any visual defect e.g. scotoma, blindness in one eye, reduced visual field, blurred vision, coloured blind?
*
Yes
No
4.6 If answered yes, please give details.
4.7 Raised or low blood pressure?
*
Yes
No
4.7 If answered yes, please give details.
4.8 Any blood disorder?
*
Yes
No
4.8 If answered yes, please give details.
4.9 Asthma, bronchitis, emphysema, pneumonia or any other lung disease?
*
Yes
No
4.9 If answered yes, please give details.
4.10 Jaundice or any form of hepatitis or other liver problem?
*
Yes
No
4.10 If answered yes, please give details.
4.11 Any kidney or bladder conditions?
*
Yes
No
4.11 If answered yes, please give details.
4.12 Arthritis, gout, chondromalcia patellae or rheumatism?
*
Yes
No
4.12 If answered yes, please give details.
4.13 Any metabolic disorder including diabetes, thyroid and adrenal gland disease?
*
Yes
No
4.13 If answered yes, please give details.
4.14 Psoriasis, eczema, allergic skin rash or other skin disorder?
*
Yes
No
4.14 If answered yes, please give details.
4.15 Any infectious diseases?
*
Yes
No
4.15 If answered yes, please give details.
4.16 Anxiety/depression, mental breakdown or stress related problems?
*
Yes
No
4.16 If answered yes, please give details.
4.17 Substance misuse (e.g. drugs, steroids)?
*
Yes
No
4.17 If answered yes, please give details.
4.18 Any allergies including hayfever?
*
Yes
No
4.18 If answered yes, please give details.
4.19 Any malignancies or cancers?
*
Yes
No
4.19 If answered yes, please give details.
4.20 Any operations or surgical procedures?
*
Yes
No
4.20 If answered yes, please give details.
4.21 Ear or hearing problems?
*
Yes
No
4.21 If answered yes, please give details.
4.22 Any other medical condition?
*
Yes
No
4.22 If answered yes, please give details.
4.23 Have you ever consulted an orthopaedic surgeon, chiropractor, osteopath or physiotherapist?
*
Yes
No
4.23 If answered yes, please give details.
4.24 Current treatment. Are you currently attending a hospital/GP for treatment or waiting for an appointment?
*
Yes
No
4.24 If answered yes, please give details.
5. Past Medical History
5.1 Have you ever failed a medical examination (or had special conditions imposed) for any employment reasons or life assurance?
*
Yes
No
5.1 If answered yes, please give details.
5.2 Have you previously been notified that you would not be eligible for ill health benefits
*
Yes
No
5.2 If answered yes, please give details.
5.3 Have you ever left a job or had to be medically retired due to ill health?
*
Yes
No
5.3 If answered yes, please give details.
5.4 Has any previous occupation caused you health problems?
*
Yes
No
5.4 If answered yes, please give details.
5.5 Are you in receipt of a medical pension or other disability benefit?
*
Yes
No
5.5 If answered yes, please give details.
6. Sickness Absence
Please list how many days you have been absent from work, school, college etc in the last three years due to sickness. For each absence please also indicate the dates and the reason.
Please provide dates of absence & reason (please state if related to a disability)
7. Alcohol History
Average Units over 7 days
*
How much alcohol on average do you consume over a seven day period? Units per week 1 unit = 1/2 pint beer = 1 glass of wine = 1 measure of spirits
8. DECLARATION
I declare that the information given in this questionnaire is true and complete. I understand that any misleading information or any omissions will be sufficient grounds for termination of my employment. I will notify you immediately if any of my answers change on my completed questionnaire. I do give permission to my General Practitioner to disclose relevant information to McColl’s Group Limited/McColl's Travel Limited in accordance with the Access to Medical Records Act 1988. I do not wish to see my General Practitioner’s comments before the questionnaire is returned to McColl’s Group Limited/McColl's Travel Limited
*
I accept
Confirm date of declaration acceptance
*
Submit