Employee Medical Questionnaire

CONFIDENTIAL

Employee Medical Questionnaire

This questionnaire must be completed by employees on induction, return to work after illness and/or return to work after travel abroad.

Name:

Job Title:

ARE YOU:
A new employee Yes/No
Returning to work after illness Yes/No
Returning to work after travel abroad Yes/No

Have you, in the past 2 weeks/during your absence, experienced, or are currently experiencing, any of the following symptoms
(Please tick all that apply)

Abdominal pain           Vomiting Fever            Diarrhoea
Skin trouble affecting your hands, arms or face
Red or swollen wounds/cuts on hands or forearms

Has anyone in your household suffered with diarrhoea or vomiting in the past 2 weeks? Yes/No

If you have ticked any of the above you must tell your manager before you handle any food.This is because many of the symptoms listed above may be associated with food poisoning and your manager may need to ask you more questions or ask you not to work with food until you are better.

I declare that all of the above statements are true and complete to the best of my knowledge
and belief.

Signature                                                                           Date

Name in Capitals