Pre-Employment Form

Section 1 - General Information

Company Name:
Candidate Surname:
Candidate Firstname(s):
Proposed Position Title:
Address:
Contact Telephone:
Email Address:
Date of Birth:

Marital Status
Single
Married
Cohabiting
Divorced
Widow(er)

General Practitioner:

Section 2 - Occupational History

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

Employment 1:
Employment 2:
Employment 3:
Employment 4:
Employment 5:

Have you been out of work in the last three years due to illness or injury?
Yes
No

If Yes Give Reason:
When & Length of Absence:
How Many Episodes:

Section 3 - Personal History

Do you smoke?
Yes
No
Ex-Smoker

If yes, how many per day?
If ex-smoker, when did you quit?

Do you drink alcohol?
Yes
No
Ex-Drinker

If yes, how many units per day?
If ex-drinker, when did you quit?

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

Do you exercise?
Yes
No

If yes, type of exercise?
If yes, frequency of exercise?

Section 4 - Family History

Father
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Mother
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Sibling 1
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Sibling 2
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Sibling 3
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Sibling 4
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Sibling 5
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Child 1
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Child 2
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Child 3
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Child 4
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Child 5
Alive
Deceased

If alive, age & current health? If deceased, cause & age of death?

Section 5 - Medical History

How would you consider your state of health?
Excellent
Good
Fair
Poor

Were you ever or are you currently under medical care?
No
Yes

If yes, please provide details.

Did you ever or are you due for surgery?
No
Yes

If yes, please provide details.

Are you currently taking any form of medication?
No
Yes

If yes, please provide details.

Are you allergic to any medication or chemical?
No
Yes

If yes, please provide details.

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?
Yes
No

Joint pains, stiffness, arthritis or other disorders of the hip, lower limbs, feet?
Yes
No

Joint pains, stiffness, arthritis or other disorders of the back, neck?
Yes
No

Muscle pains, tendonitis, soft tissue disorders?
Yes
No

Numbness, tingling of hand, foot, other sites?
Yes
No

Weakness, loss of power of your hand, limb?
Yes
No

Dizzy spell, fits, faints, collapse, black out?
Yes
No

Visual blurring, loss of vision, other visual disorders?
Yes
No

Migraine, Headaches?
Yes
No

Sinus problem, nasal congestion, facial pains, hay fever?
Yes
No

Ear infection, deafness, tinnitus (buzzing in ear), other ear disorder?
Yes
No

Mouth ulcer, poor dentition, weight loss, poor appetite?
Yes
No

Problem swallowing, heart burn, gastric reflux, indigestion, ulcer?
Yes
No

Abdominal pains, change in bowel habit, blood in stools?
Yes
No

Wheeze, cough, coughing up phlegm or blood, difficulty breathing?
Yes
No

Asthma, tuberculosis, other lung condition?
Yes
No

Chest pain, shortness of breath, palpitation, poor exercise tolerance?
Yes
No

Angina, heart attack, irregular heartbeat, other heart condition?
Yes
No

Stroke, transient ischemia attack, high blood pressure, meningitis?
Yes
No

Urinary or kidney disorder, recurrent urine infection, kidney stone?
Yes
No

Gynaecological, obstetric problem?
Yes
No

Thyroid disorder, diabetes, other glandular disorders?
Yes
No

Chronic fatigue, low energy, poor motivation, withdrawn?
Yes
No

Mood disorder, depression, anxiety or stress-related symptoms?
Yes
No

Psychiatric disorder, addiction problem?
Yes
No

Problem sleeping?
Yes
No

Eczema, contact dermatitis, skin allergy, psoriasis, dry skin, other skin disorder?
Yes
No

Fear of height, open spaces, confined space, flying?
Yes
No

Problem with speech and language?
Yes
No

Other significant medical symptoms or conditions?
Yes
No

Previous investigations, treatment for any medical condition including physiotherapy?
Yes
No

Previous exposure to chemical, dust, gas, noise, biological hazards?
Yes
No

Difficulty with shift work, night work?
Yes
No

Are there any tasks you cannot perform due to a health reason or disability?
Yes
No

Are you aware of any need for job modification that you may require?
Yes
No

Have you ever had a compensation claim due to ill health or injury?
Yes
No

Did you ever have to give up a job due to ill health or injury?
Yes
No

Section 5c - Medical History

If you answered yes to any question in section 5b, please give details here:

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):

Business Health Ireland providing a certificate of my fitness to work (with appropriate recommendation on job accommodation if required)
Business Health Ireland liaising with my GP concerning my health.
Undergoing an appropriate medical examination.

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