Health Form
Important Information
The role of Care worker / Support worker / Registered Nurse which you are applying for is within Health, Social and Nursing care. Therefore these roles involve manual and people handling, physically supporting and assisting those who are vulnerable and undertaking everyday tasks they may not be able to undertake themselves. For example: Carrying shopping, changing bedding, housekeeping, dressing, assisting to transfer into a bed or from a chair into a bath and other forms of people handling.
Local Care Force is committed to promoting equal opportunities in employment. All employees, temporary workers and job applicants will receive equal treatment regardless of age, disability, gender reassignment, marital or civil partner status, pregnancy or maternity, race, colour, nationality, ethnic or national origin, religion or belief, sex or sexual orientation.
Nearest Branch
Please specify the branch you are closest to.
Leeds

Manchester

Sheffield

Department(s)
Please specify the department(s) you are applying to.
Nursing

Care

Support

About You
Please provide your personal details.
First/Middle Names *

Surname *

DOB *

Please select your gender.
Male

Female

Personal Health
Do you have any health issues or a disability which may make it difficult for you to carry out functions that are essential for the role you seek?
Yes

No

If yes please summarise below so we can discuss at registration.
Details

Night Worker Questionnaire (Please only complete if you intend to work any night shifts)
Do you suffer any of the following conditions?
Diabetes
Yes

No

Heart or circulatory disorders
Yes

No

Stomach or intestinal disorders
Yes

No

Any conditions which causes difficulties sleeping
Yes

No

Chronic chest disorders (especially if night-time symptoms)
Yes

No

Any medical condition requiring medication to a strict timetable
Yes

No

Any other health factors that might affect fitness at work
Yes

No

If you have answered ‘yes’ to any of the above questions, you may be asked to see a doctor or nurse
Immunisation History
MMR
Yes

No

If YES, please give date of inoculation

Tetanus
Yes

No

If YES, please give date of inoculation

TB / BCG
Yes

No

If YES, please give date of inoculation

Polio
Yes

No

If YES, please give date of inoculation

Triple Vaccination as a child (Diptheria/Tetanus/Whooping cough)
Yes

No

If YES, please give date of inoculation

Varicella (Chickenpox)
Yes

No

If YES, please give date of inoculation

Have you had Chickenpox or Shingles?
Yes

No

Please Answer The Following Questions About Hepatitis B
Have you had a Hep B immunisation?
Yes

No

If yes, please enter the date of inoculation. If unknown please leave blank.
Inoculation Date

If you have answered no, are you currently undertaking a course of HEP B or will arrange as soon as possible and evidence will be provided once completed.
Yes

No

I refuse to have a course of Hepatitis B vaccination and know the implications and risk of this.
Yes

Have you lived continuously in the UK for last 5 years?
Yes

No

If you answered no above, please list all the countries that you have lived in over the last 5 years.
Countries

Please Confirm
I hereby confirm that the information I have given is true and correct. I agree to inform Local Care Force of any changes to the information given and understand that if false statements are made, it may result in termination of my assignment and my registration with the agency terminated.
Print Name *

Date *

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