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Medical Questionnaire
Full Name
Date of Birth
Email
Home Tel
Work Tel
Mobile Number
Home Address
Street Address
Address Line 2
City
County
Postal Code
If you have indicated yes to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned/rejected.
Yes
No
Do you have any illness/impairment/disability (physical or psychological) which may affect your work?
Yes
no
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
Yes
no
Are you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide further details of the condition, treatment and dates
Yes
no
Do you think you may need any adjustments or assistance to help you do the job?
Yes
no
Have you suffered from any of the following:
Methicillin Resistant Staphylococcus Aureus (MRSA)?
Yes
no
Clostridium Difficile (C-Diff)?
Yes
no
Chicken Pox or Shingles
Have you ever had chicken pox or shingles?
Yes
no
BBV (Blood Borne Virus)
Have you ever come into contact with any BBV’s? Including Needle Stick Injuries?
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
Tuberculosis Continued
Do you have any of the following?
A cough which has lasted for more than 3 weeks
Yes
no
Unexplained weight loss
Yes
no
Unexplained fever
Yes
no
Have you had tuberculosis (TB) or been in recent contact with open TB
Yes
no
Have you had any of the following immunisations?
Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)
Yes
no
Polio
Yes
no
Tetanus
Yes
no
Hepatitis B
Yes
no
Proof of Immunity (Please send the following)
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Will your role involve Exposure Prone Procedures ?
Yes
no
All information you provide will be treated with strict confidentiality and managed in accordance with the UK General Data Protection Regulation (GDPR). Records will be stored electronically following best practice standards and may be subject to audit when required.
If you are registered with other partner organisations of Ever Nurse, your information may be cross-referenced to ensure compliance and accuracy.
Your personal data may be reviewed by an occupational health advisor or physician where necessary. However, it will not be shared with managers, HR personnel, GPs, specialists, or any third parties without your explicit consent.
You have the following rights under GDPR:The right to erasure (“right to be forgotten”)
The right to refuse or withdraw consent at any time without detriment
The right to access, update, or correct your dataConsent is an ongoing process, not a one-time action.
For consent to be valid, it must be given voluntarily and with full understanding. You may withdraw your consent at any stage, either verbally or in writing.
The only exceptions to confidentiality are legal obligations such as a court order or matters of public interest.For more information on your data protection rights, visit:
https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/
To view our privacy policy or request more details, please contact
info@evernurse.co.uk
.
Do you consent to this questionnaire and your immunisation reports 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 Advisors speaking with you regarding any declaration you may have made relating to your medical history?
Yes
no
Do you consent to our Occupational Health Advisors making recommendations to your employer/agency to assist with your ability to carry out your prospective 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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