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Brooklands Court, Carr Moor side, Leeds, England, LS11 5HL
info@phstaffingplus.co.uk
0113 322 4566

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Over 10 years we helping companies reach their financial and branding goals. Onum is a values-driven SEO agency dedicated.

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411 University St, Seattle,

10005, USA
onum_company@mail.com
+1-800-456-478-23

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Health Declaration

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Health Declaration

HEALTH DECLARATION

HEALTH DECLARATION

Are you in good health? *

Are you willing to undergo a medical examination, if required?

Have you ever suffered from, or do you currently suffer from any of the following?

Back pain, disc trouble, rheumatism, arthritis, gout

Dermatitis, eczema, or other skin disorders

Any form of alcohol or substance dependency

Epilepsy, fainting attacks, or black outs

Palpitations, shortness of breath, chest pain

High blood pressure, or, any other ailment of the heart, lungs, chest or circulatory system

Mental Health issues e.g. Depression, anxiety or other

Any visual or hearing defects

Have you ever suffered from, or do you currently suffer from any of the following?

Diabetes, anaemia, or, any blood or gland disorder

Rheumatic fever, or any joint / muscular problems

Recurring headaches

Ulcers, gall stones, or any ailment of the intestines or liver

Any known allergies

None of the above

Do you have any other illness not referred to above?

If Yes, please specify:

Do you have any other pre-existing health related condition that would impact your ability to work?

Please provide details of all absenses from work due to illness or injury in the last year (please include reasons and durations):

Declaration: I declare that the information given is, to the best of my knowledge and belief, complete and correct. I understand that any information disclosed will be dealt with in compliance with the Data Protection Act 1998. Any information to be shared with a third party will be done with my prior knowledge and consent. I undertake to notify PH Staffing of any ill health which subsequently occurs. PLEASE SIGN BELOW:

FULL NAME:

Today’s Date:

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Limited Company Registered in England and Wales, Professional Healthcare Staffing
Company Reg No: 16798432

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Get in Touch with us

Address: Brooklands Court, Carr Moor side, Leeds, England, LS11 5HL
24hrs Oncall Line : +44 33 0133 0060
Office Line : 0113 322 4566
Out Of Hours : +44 (0) 745 9639 263
Enquiries Contact : info@phstaffingplus.co.uk
Training Contact :training@phstaffingplus.co.uk

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