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Medical Questionnaire

The document is a pre-employment medical questionnaire for Gustavo Enrique Afosno Isturiz, requesting information about his medical history, absences from work, and any current treatments or disabilities. It emphasizes the confidentiality of the information provided and its use for compliance with health and safety regulations. The individual must confirm the accuracy of the information and consent to data collection in accordance with the Data Protection Act 1998.

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Cynthia Ruz Lopez-Escobar
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6 views1 page

Medical Questionnaire

The document is a pre-employment medical questionnaire for Gustavo Enrique Afosno Isturiz, requesting information about his medical history, absences from work, and any current treatments or disabilities. It emphasizes the confidentiality of the information provided and its use for compliance with health and safety regulations. The individual must confirm the accuracy of the information and consent to data collection in accordance with the Data Protection Act 1998.

Uploaded by

Cynthia Ruz Lopez-Escobar
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE

GUSTAVO ENRIQUE AFOSNO ISTURIZ


Full Name:
Address: CALLE MATAHACAS 9-11 1ºA

630051039
Contact No:

We will not contact your doctor without your prior written consent.

1. How many days of absence have you had from


Days:
work in the last three years?

How many periods of absence have you had in


Periods: During the pandemic (3 months)
last three years?

2. Are you currently on medication or have you


been prescribed medication (excluding NO
contraceptives)? If YES, please give further
details.

3. Are you currently receiving treatment for any


physical or mental condition? NO
If YES, please give further details.

4. Do you suffer from any injury, illness, medical


condition or allergy that might affect your ability
NO
to perform your duties?
If YES, please give further details.

5. Do you consider yourself to have a


NO
disability? If YES, please give further
details.

Data Protection Notice:

The Company requires certain information prior to you commencing employment, to ensure you will
be able to perform the requirements of the job and give reliable service, and to ensure compliance
with relevant Health and Safety regulations. The information is also required in order to establish
whether any reasonable adjustments may need to be made to assist you in performing your
duties, in accordance with the Disability Discrimination Act 1995.

The information you provide will be treated in the strictest confidence, and used only for the purposes
detailed above in compliance with the Data Protection Act 1998.

I confirm that the information given in this questionnaire is complete and accurate to the
best of my knowledge. I consent to the Company collecting and retaining this date in
accordance with the Data Protection Act 1998.

Signature: Date:

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