Confidential Health Declaration Form

Collects an employee's or applicant's medical history and health declarations before they start a role, including illness history, immunizations, and relevant background disclosures.

Use this template

Personal Details

Name

Nombre

Apellido

Branch

Date

How many days of sick leave have you had in the past 2 years? Please give approximate dates, reason, and number of days taken.

Do you currently have an illness or take any prescribed medication? If yes, please give details.

Have you previously been diagnosed with a serious illness that could recur? If yes, please give details.

Have you ever had or been treated for MRSA?

Do you have or have you ever had a bad back? If yes, please give details.

Have you had, or are you waiting to have, any major surgery? If yes, please give details.

Have you ever been treated, or are you currently receiving treatment, for mental health problems?

Immunization History

Tetanus

Polio

MMR

Rubella

Varicella (Chicken Pox)

Hepatitis 'B'

Infectious Disease History

Have you had Chicken Pox?

Have you had Shingles?

Do you consider yourself as having a disability? If yes, please give details.

Do you require any special considerations or reasonable adjustments in respect of your disability, illness, or diagnosis? If yes, please give details.

Applicant Declaration

Signature

Sign here

Have you ever been cautioned or convicted of any offence? If yes, please give details (this must be disclosed even where a conviction might otherwise be considered spent under applicable law).

Is there any charge against you that remains to be dealt with by any court? If yes, please give details.

Other Relevant Facts

Applicant Signature

Signature

Sign here

Witness Signature

Signature

Sign here

Confidential Health Declaration Form

Related templates