Health Questionnaire – City Group Security Ltd

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Night worker health questionnaire
This questionnaire is designed to help assess if you have any health condition or circumstance that could affect your ability to perform night work and determine whether there is a need for you to undergo a medical examination. The cost of this will be met by the Company if this is required.
Do you have any medical condition that requires regular medication?*
Do you suffer from any chronic chest disorder where night-time symptoms are troublesome?*
Do you suffer from diabetes where treatment with insulin injections on a strict timetable is required?*
Do you suffer from any heart or circulatory disorder, which affects your physical stamina?*
Do you have any medical condition that affects your sleep?*
Do you suffer from any stomach or intestinal disorder such as ulcers where the timing of a meal is important?*
Are there any personal circumstances that prevent you working nights?*
If YES to any of the above, please give details here?*
Doctor's Information
The Name of my Doctor is:*
Doctor's Telephone No:*
Doctor's Address*
Street Address City Postcode Country
Signature
I declare that the information given on page one and page two is true and accurate to the best of my knowledge. I understand that wilful false representation and dishonesty is regarded as gross misconduct and can lead to summary dismissal.
Employee’s Signature*
I hereby authorise City Security Services Limited to contact my doctor to verify the above information.
Date*
Page 2 of 2

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