hcs 245 Health Questionnaire

Health Questionnaire

Please read the questions carefully and answer each to the best of your ability, circling the appropriate option or adding information if necessary. Your responses will of course be kept in the strictest confidence.

Personal Details

Surname: Forename:
Date of Birth:     /       /         (dd/mm/yyyy)          

Sex:         Male               Female

Home Address:

Post Code:                                           Home Phone Number:

Mobile Number:                                   E-Mail Address:

Nationality:                                          

Which activity do you plan to be participating in?

Emergency Contact Details

Mr/Mrs/Miss

Surname: Forename:

Home Address:

Post Code: Home Phone Number:

Mobile Number: Work Phone Number:

Relationship to Candidate:

Please answer all of the following questions to the best of your knowledge. Circle the answer that best suits you, and if answering yes to any of the questions, please use the space provided to give details if necessary.