Health Questionnaire

Home
Services
Work For Us
About Us
Team Pictures
Contact Us

Home
Services
Work For Us
About Us
Team Pictures
Contact Us

0130 248 1515

Twitter Instagram

How many days were you absent from work due to sickness in the last year?

Have you ever suffered from: Allergies, eczema, dermatitis or other skin troubles?

Yes No

Do you suffer from: Epilepsy, migraine, asthma, angina, heart trouble or any condition requiring long-term medical help or a strict medication timetable? *

Yes No

Have you ever suffered from: Mental illness including anxiety, depression or nervous debility?*

Yes No

Have you ever required treatment for: Hernia or rupture, rheumatism, back problems, slipped disc, sciatica or Repetitive Strain Injury (RSI)?*

Yes No

Do you suffer from: Diabetes, ulcers, stomach or other intestinal disorders?*

Yes No

If you have answered yes to any of the questions above, please provide further details below.

Health Declaration

I hereby confirm that I know of no reason, in relation to either my physical or mental health, why I would be unable to undertake the duties required for the post applied for.

Data Consent

In ticking the following box and submitting the data completed in the above form you agree to us processing the information as stated at the start of the form. You will need to tick the box prior to submission.

Instructions

When submitting this form it will generate an email to Embrace Health Care. The information completed is the first part of the application process and on the successful submission you will be redirected to the Health Questionnaire. When completing this form please use the same email address as used as part of this submission. We will not process an application until we have received the “Job Application”, “Health Questionnaire”, “Equal Opportunities” and the “ID Verification Form” and the “Rehabilitation of Offenders Declaration”.

Disclaimer

Embrace Health Care will not accept a partially complete application and if any of the forms are missing we can not guarantee your application will be considered. For each form you will receive a confirmation email confirming the submission and we recommend that you retain this as proof. On submission you will be redirected to the next form but you do not need to complete within a specified time as long as all are received prior to the closing data of the advertised position.

Download Form

Home
Services
Work For Us
About Us
Contact Us

Embrace Health Care
CQC overall rating

Good

See the report

Facebook Twitter Instagram