Email: enquiries@edenrosecarerecruitment.co.uk
Phone: 0333 404 8926
Application Form

Page 6

APPLICATION FORM - CARE WORKERS

HEALTH DECLARATION/MEDICAL QUESTIONNAIRE

Please complete the following questionnaire regarding your health status and your fitness to carry out the duties as described in the job description of a Home Carer.

Please give details if you have suffered from any of the following and give dates.

Description
Mental Health Condition that required hospital treatment and/or drug treatment?

Examples
Depression, bipolar disorder schizophrenia, anxiety, alcoholism, drug dependency

Details & Dates

Description
Chest complaint, breathing, pain or condition that required hospital treatment or surgery or is being treated with drugs?

Examples
TB, cancer, asthma, emphysema, angina, heart condition, heart attack, high blood pressure

Details & Dates

Description
Back pain that is receiving hospital treatment and/or drug treatment?

Examples
Sciatica, spondylitis, disc degeneration

Details & Dates

Description
Arthritis that is receiving hospital treatment or drug treatment?

Examples
Rheumatoid, osteo

Details & Dates

Description
Epilepsy, blackout, vertigo receiving (received) hospital treatment and/or drug treatment?

Examples
Fits, giddy attacks

Details & Dates

Description
Stomach, kidney or bowel condition that required Hospital treatment and/or drug treatment?

Examples
Cancer, colitis, pancreatitis, gall bladder, hernia

Details & Dates

Description
Diabetes, thyroid or other glandular problems that required Hospital treatment and/or drug treatment?

Examples

Details & Dates

Description
Infectious or contagious disease that required or requires Hospital treatment and/or drug treatment?

Examples
Hepatitis, HIV/AIDS, MRSA, diarrhoea, vomiting, skin disease, dysentery

Details & Dates

Description
Is your eyesight and hearing good?

Examples
Do you wear glasses or a hearing aid?

Details & Dates

Description
Do you suffer from any allergies?

Examples
Hay fever, reactions to drugs, food and fumes

Details & Dates

Description
Are you pregnant?

Examples

Details & Dates




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RECOMMENDATIONS

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Address

41 Blenheim Square,
North Weald Bassett,
Epping

Contact

Email: enquiries@edenrosecarerecruitment.co.uk
Phone: 0333 404 8926

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