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Annual Medical Questionnaire
Full Name
Date of Birth
Home Tel
Work Tel
Mobile Tel
Home Address
Street Address
Address Line 2
City
Zip / Postal Code
County / State / Region
Country
GP Address
Street Address
Address Line 2
City
Zip / Postal Code
County / State / Region
Country
Changes to Your Health
I confirm that I have reviewed my health questionnaire and there has been no changes to my health in the past year
Yes
No
I confirm that I have reviewed my health questionnaire and I have listed the changes below
Yes
No
Have you come into contact with any BBV’s (Blood Bourne Virus) since you were initially screened by Occupational Health including Needle Stick Injuries?
Yes
No
Have you suffered from methicillin resistant staphylococcus aureus (MRSA)?
Yes
No
Have you suffered from clostridium difficile (C-Diff)?
Yes
No
Tuberculosis
Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006) *
Have you lived continuously in the UK for the last year (Include Holidays/ Vacations)
Yes
No
Have you had a BCG vaccination in relation to Tuberculosis?
Yes
No
Do you have a cough which has lasted for more than 3 weeks?
Yes
No
Do you have any unexplained weight loss?
Yes
No
Do you have any unexplained fever?
Yes
No
UK General Data Protection Regulation (UK GDPR)
All information you provide will be treated with the strictest confidence and processed in line with General Data Protection Regulation (GDPR) requirements. Records will be securely stored electronically and may be subject to audit in line with best practice.If you are registered with other clients or partners of Ever Nurse, your data may be cross-referenced for compliance purposes. Your personal information may also be reviewed by an occupational health advisor or physician when necessary; however, no details will be shared with managers, HR personnel, GPs, specialists, or third parties without your explicit written consent.You have the right to:Refuse or withdraw consent at any time without detriment. Request erasure of your data (“the right to be forgotten”) Access information held about you upon requestThe only exceptions to confidentiality are instances where a legal obligation exists, such as a court order or a matter of public responsibility.For more details on your rights under GDPR, please visit:
https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/
To request a copy of our full privacy policy, please contact us at
info@evernurse.co.uk
Consent
Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing. Further information regarding consent is available on the 'candidate screening leaflet'
Do you consent to this questionnaire, and any supporting documentation, being assessed by an Occupational Health Advisor for the purpose of providing a Fitness to Work Certificate?
Yes
No
Do you consent to our Occupational Health Advisor speaking with you regarding any declaration you may have made relating to your medical history?
Yes
No
Do you consent to our occupational Health Advisor making recommendations to your employer/agency to assist with your ability to carry out your perspective role?
Yes
No
Declaration
I will inform my employer if I am planning to or leave the UK for longer than a three month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.
Full Name
Applicant/Candidate's Email
Date
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