This questionnaire helps you spot any health support or adjustments a new starter needs before they begin, so the job can be done safely from the start.
This form template is supplied in fully editable MS Word format and can be easily customised and edited. The document uses pre-defined style formatting throughout, with all text in Calibri font for improved readability.
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Medical Questionnaire Form Template
This medical questionnaire is a health questionnaire for a new employee, completed after an offer of employment, to identify any support or adjustments needed to carry out the job safely. The employee answers yes, no or not sure to questions on health conditions, treatment, medication, sensory difficulties, musculoskeletal conditions, sleep and everyday physical activities, then signs a declaration.
In a management system it supports hazard identification for the individual, as ISO 45001 clause 6.1.2 includes human factors when identifying hazards. The form is marked Confidential.
Built for Safe Placement of New Starters
The questionnaire flags health matters that may need support before work starts.
- Identifies conditions or disabilities where support or adjustments at work may be needed.
- Highlights the risk of sudden incapacity, drowsiness from medication or sleep disorders for safety critical tasks and driving.
- Picks up skin conditions, asthma or allergies, including latex allergy, that could be affected by substances or materials at work.
- Records any health condition or injury caused or made worse by work.
- Checks for difficulty with physical activities such as standing, lifting, driving and manual dexterity.
What's Included in this Medical Questionnaire
Each question has yes, no and not sure columns.
- Employee details - name, date and job role or work area.
- Health questions - physical or mental health conditions or disability, treatment or investigations, conditions that could cause sudden loss of consciousness or incapacity, medication that could affect safe working, skin conditions, asthma or allergies, work related conditions or injuries, hearing, sight or speech difficulties, musculoskeletal conditions and sleep disorders.
- Activities - difficulty with standing, walking, sitting, stair climbing, lifting, driving, kneeling, squatting or bending, manual dexterity and co-ordination.
- Details - a prompt to give details of any yes answer.
- Declaration - confirmation that the information is complete and accurate, that it is held in confidence and that changes will be reported, with signature and date.
Using the Medical Questionnaire
Ask the new employee to complete the questionnaire once an offer of employment has been made. Where they answer yes to any question, the details they give are the starting point for a conversation about any support or adjustments they may need before they start the role.
Keeping the Completed Questionnaire
The completed form holds health information and is marked Confidential. Keep it apart from the general personnel file, limit access to those who need it, and update the record when the employee tells you about a change, as the declaration asks them to.
Who Needs a Medical Questionnaire?
Employers where the work involves physical tasks, driving, machinery, substances or safety critical duties, and any business that wants to plan adjustments early. The new starter completes it after the offer is made, and it is reviewed in confidence by the person responsible for HR or health and safety.
Pairs with the Employee Personal Details Form
The questionnaire is usually completed alongside the F-HR1 Employee Personal Details form when a new employee is set up.