Healthy Questionnaire - ClubSENsational

Personal information

Name *

Last name *

Date of birth *

Position applied for *

General health questions

Please answer by ticking Yes or No. If you answer "Yes" to any question, provide additional details in the space provided.

1. Do you have any medical conditions that may affect your ability to perform your role? *

Yes No

If yes, please specify:

2. Are you currently taking any medication that may impact your work duties? *

Yes No

If yes, please specify:

3. Do you have any allergies (e.g., food, medication, latex)? *

Yes No

If yes, please specify:

4. Have you ever had or do you currently have any mental health conditions (e.g., anxiety, depression) that may impact your role? *

Yes No

If yes, please specify:

5. Have you ever had any musculoskeletal conditions (e.g., back pain, joint issues) that may affect your ability to lift or move individuals? *

Yes No

If yes, please specify:

6. Have you ever had any respiratory conditions (e.g., asthma, COPD) that may affect your ability to perform your duties? *

Yes No

If yes, please specify:

7. Do you have any vision or hearing impairments that may impact your role? *

Yes No

If yes, please specify:

8. Have you ever had any communicable diseases (e.g., tuberculosis, hepatitis)? *

Yes No

If yes, please specify:

9. Have you had any surgeries or hospital admissions in the last 12 months? *

Yes No

If yes, please specify:

10. Do you have any conditions that require workplace adjustments? *

Yes No

If yes, please specify:

Declaration

I confirm that the information provided is accurate to the best of my knowledge. I understand that failure to disclose relevant health information may impact my employment.

I confirm that the information provided is accurate to the best of my knowledge. I understand that failure to disclose relevant health information may impact my employment. I consent to this information being used for occupational health assessment purposes.

Date *

Signature *

Confidentiality & Data Protection
All information provided in this form will be kept strictly confidential and used solely for occupational health assessment purposes. It will be handled in accordance with data protection laws and will not be shared without your consent, except where required by law.

Pre-Employment Health Questionnaire

Personal information

General health questions

Declaration

I confirm that the information provided is accurate to the best of my knowledge. I understand that failure to disclose relevant health information may impact my employment.