Section 1 - General Information

Marital Status

Section 2 - Occupational History

Please list most recent Employer & Position held listing them in Chronological order please include approx start & end dates

Have you been out of work in the last three years due to illness or injury?

Section 3 - Personal History

Do you smoke?

Do you drink alcohol?

One Unit is one glass of wine or one measure of a spirit or half a pint of beer

Do you exercise?

Section 4 - Family History



Sibling 1

Sibling 2

Sibling 3

Sibling 4

Sibling 5

Child 1

Child 2

Child 3

Child 4

Child 5

Section 5 - Medical History

How would you consider your state of health?


Were you ever or are you currently under medical care?

Did you ever or are you due for surgery?

Are you currently taking any form of medication?

Are you allergic to any medication or chemical?

Section 5b - Medical History (Did you ever suffer from / are you suffering from)

Joint pains, stiffness, arthritis or other disorders of the shoulder, upper limbs, hands?

Joint pains, stiffness, arthritis or other disorders of the hip, lower limbs, feet?

Joint pains, stiffness, arthritis or other disorders of the back, neck?

Muscle pains, tendonitis, soft tissue disorders?

Numbness, tingling of hand, foot, other sites?

Weakness, loss of power of your hand, limb?

Dizzy spell, fits, faints, collapse, black out?

Visual blurring, loss of vision, other visual disorders?

Migraine, Headaches?

Sinus problem, nasal congestion, facial pains, hay fever?

Ear infection, deafness, tinnitus (buzzing in ear), other ear disorder?

Mouth ulcer, poor dentition, weight loss, poor appetite?

Problem swallowing, heart burn, gastric reflux, indigestion, ulcer?

Abdominal pains, change in bowel habit, blood in stools?

Wheeze, cough, coughing up phlegm or blood, difficulty breathing?

Asthma, tuberculosis, other lung condition?

Chest pain, shortness of breath, palpitation, poor exercise tolerance?

Angina, heart attack, irregular heartbeat, other heart condition?

Stroke, transient ischemia attack, high blood pressure, meningitis?

Urinary or kidney disorder, recurrent urine infection, kidney stone?

Gynaecological, obstetric problem?

Thyroid disorder, diabetes, other glandular disorders?

Chronic fatigue, low energy, poor motivation, withdrawn?

Mood disorder, depression, anxiety or stress-related symptoms?

Psychiatric disorder, addiction problem?

Problem sleeping?

Eczema, contact dermatitis, skin allergy, psoriasis, dry skin, other skin disorder?

Fear of height, open spaces, confined space, flying?

Problem with speech and language?

Other significant medical symptoms or conditions?

Previous investigations, treatment for any medical condition including physiotherapy?

Previous exposure to chemical, dust, gas, noise, biological hazards?

Difficulty with shift work, night work?

Are there any tasks you cannot perform due to a health reason or disability?

Are you aware of any need for job modification that you may require?

Have you ever had a compensation claim due to ill health or injury?

Did you ever have to give up a job due to ill health or injury?

Section 5c - Medical History

Section 5 - Declaration

By submitting this form to Business Health Ireland, I, hereby
confirm that I understand the nature of this assessment and that I have voluntarily completed this medical questionnaire.

I understand that my medical details will be held in confidence by Business Health Ireland and that no medical information will be released without my informed consent.

I confirm that all information provided is accurate to the best of my knowledge. I am aware that failure to disclose relevant medical information or the provision of false information may result in either cancellation or variation of any offer of employment.

I consent to (please tick each box to confirm consent):

I consent to Business Health Ireland disclosing relevant medical information to a named contact in the company.