Tuberculosis [TB] or in the last 12 months had unexplained weight loss, night sweats, cough lasting more than 3 weeks or coughing up blood

Skin problems or allergies including latex allergy (e.g. eczema, asthma or dermatitis) or an adverse reaction to any medicine or substance

Musculoskeletal condition that may affect ability to perform work tasks

(including back pain lasting > 2 weeks, arthritis or bony injury or deformity)

Mental health problem or illness (e.g. nerves, phobias, stress, anxiety, depression, eating disorders), or drug or alcohol dependency or misuse (including prescription drugs or recreational drugs)

Tested positive for infection for HIV, hepatitis B or hepatitis C

Do you have a medical condition that may affect your ability to perform the proposed job?

Have you had any health condition or injury caused or made worse by work?

Are you at present taking any form of medication (excluding contraception)?

(Give name and dosage of any drugs below).

Are you attending or waiting to attend hospital treatment or investigation?

Do you have a disability or health condition not mentioned above that may require additional help or support to perform the work tasks?

How many sick days have you had over the past 2 years (including if you were not working – give reasons below if more than 10 days in total)