Medical Questionnaire

Applicants should be read the following carefully

The questionnaire below should be completed as fully as possible. All questions must be
answered. The information will be treated in the strictest confidence.
WARNING: In completing the questionnaire, you are responsible for the accuracy of your statements. If
information is withheld suppressed, deliberately misleading or false, you may be held liable and this may
become a cause for your dismissal.

1. HEIGHT: WEIGHT:
2. Do you presently suffer from an illness requiring medication? YES: NO:
3. Do you presently suffer from an illness requiring hospital visit? YES: NO:
4. Do you smoke? YES: NO:
5. Do you wear glasses or contact lenses? YES: NO:
6. Is your sight in each eye good enough for all activities?
(If glasses or lenses are necessary, please indicate the grade and
kind of glasses/lens used in the space provided in page two). YES: NO:
7. Is your hearing in each ear good enough for all normal activities? YES: NO:
(If hearing aides are necessary, please explain in the space
provided in page two, which ear (right/left) is affected and what
type of hearing aide you are using).
8. Do you have a discharge from either ear?
9. Please complete the following questions 1-31 by checking the appropriate lines.

1. Fainting attack and giddiness. YES: NO:

2. Tuberculosis YES: NO:
3. Sinusitis YES: NO:
4. Bronchitis, Asthma & Pneumonia YES: NO:
5. Recurring Headaches or Migraine YES: NO:
6. Dermatitis or other skin disorders YES: NO:
7. Foot or Knee Trouble YES: NO:
8. Varicose Veins causing trouble YES: NO:
9. Rupture/Hemia YES: NO:
10. Recurrent Indigestion/Dyspopala YES: NO:
11. Kidney or Bladder Disease YES: NO:
12. Blackouts, Epilepsy or Fita YES: NO:
13. Heart Attack or Angina YES: NO:
14. Raised Blood Pressure YES: NO:
15. Diabetes YES: NO:
16. Severe Shortness of Breath YES: NO:
17. Nervous Disorder, Nerve or Breakdown YES: NO:
18. Back or Neck Trouble Sciatica Arthritis YES: NO:
19. Serious injury of accident YES: NO:
20. Have you ever had any operation or been admitted? YES: NO:
21. Are you currently being attending any hospital, clinic,
or out-patient department? YES: NO:
22. Are you currently being attend to by a doctor? YES: _NO:
23. Are you at present having any treatment prescribed
By a doctor? YES: NO:
24. Do you have any symptoms which frequently prevent
you from going to work, school, etc. for a day, two
or longer? YES: NO:
25. Do you have or have you had any defect, disorder or other
condition, mental or physical, not already mentioned in
any of your answer? YES: NO:

26. Have you left a job, or been discharge from military

forces because of ill health? YES: NO:
27. Are you in receipt of a war pension or any other
disability benefit? YES: NO:
28. Are you or have you ever been Registered Disabled? YES: NO:
29. Have you had a chest X-ray within the past 12 months? YES: NO:
30. Have you had Hepatitis? YES: NO:
31. Any Gynecological problem (for female Staff) YES: NO: