Health Assessment Questionnaire for Night Workers Health Assessment Questionnaire for Night Workers Candidate ID*Candidate Unique Key*Full Name*Date of Birth* Date Format: DD dash MM dash YYYY The following medical conditions could possibly affect your health and ability to safely carry out night work or could be made worse by night work. Do you suffer from any of these conditions?Diabetes?*YesNoHeart or circulatory problems?*YesNoStomach or intestinal problems, such as ulcers?*YesNoAny medical condition which causes difficulty sleeping?*YesNoChronic chest disorders where night time symptoms may be particularly troublesome?*YesNoAny medical condition requiring medication on a strict timetable?*YesNoAny medical condition where the timing of meals is particularly important?*YesNoAny mental health problems which may be affected by night work?*YesNoAny other medical condition which may affect your ability to work safely at night?*YesNoAre you a new or expectant mother?*YesNoIf you have worked at night before, did this cause any ill health?*YesNoIf ‘yes’ to any of the above, please give details i.e., when condition developed, is this new, how severe, its effect on you, how well controlled and treatment so far.*Do you believe that any of these are made worse by night work?*YesNoIf ‘YES’, please give details*Will you be discussing suitability of night work with your GP?*YesNoDeclaration I certify that all the answers given above are true to the best of my knowledge and belief. I understand that no medical details will be divulged without my permission to any person outside of Jubilee Recruitment. Signature*Sign as appropriate for your device with your finger, touchpad or mouse
