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Medical Questionnaire

Medical Questionnaire
1. Are there any medical reasons why you should not do shift work?
2. Are you able to carry out strenuous physical work including climbing Ladders, working from scaffolding, bending, lifting and carrying?
3. Have you ever had to give up any previous job for medical reasons?
4. Have you ever had any treatment requiring hospital admission for five or more days?
5. Is your eyesight normal (with glasses if worn)?
6. Is your hearing normal?
7. Have you ever had any of the following?
(a) Diabetes?
(b) Tuberculosis?
(c) Angina?
(d) Any other heart trouble?
(e) Raised blood pressure?
(f) Peptic, gastric or duodenal ulcer?
(g) Indigestion for more than one week?
(h) Back trouble, lumbago, sciatica, “slipped disc”?
8. Have you ever had any of the following during the past five years?
(a) Bronchitis, asthma, pneumonia?
(b) Dermatitis, eczema or any other skin troubles?
9. Do you suffer from any of the following
(a) Migraine or sever recurring headaches?
(b) Anxiety, depression or any other nervous complaint?
(c) Fainting attacks or giddiness?
(d) Kidney trouble or urinary infection?
(e) Sleep disorders?
I am willing to undergo a medical examination if required and I declare that the information I have given on this form is correct to the best of my knowledge.
I agree that the Company may consult my own Doctor in relation to any information I have given on this questionnaire.
HAVE YOU EVER BEEN FINED, IMPRISONED, PLACED ON PROBATION, DISCHARGED ON PAYMENT OF COSTS OR HAD ANY ORDER MADE AGAINST YOU BY A CRIMINAL, CIVIL OR MILITARY COURT OR PUBLIC AUTHORITY?
HAVE YOU ANY ALLEGED OFFENCES OUTSTANDING AGAINST YOU? IF YES,
ALL 786 Services Limited Employees are paid directly into their Bank Accounts. Please give details below:
Do you have any special requirements if invited for an interview.
I UNDERSTAND THAT IF I AM OFFERED EMPLOYMENT, I WILL BE APPOINTED ON PROBATION FOR A PERIOD OF 3 MONTHS.

DURING THE PROBATIONARY PERIOD, MY EMPLOYMENT WILL BE TERMINABLE BY ONE WEEK’S NOTICE BY EITHER PARTY.
 
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