The Highland Council 
Medical Questionnaire
This form should only be requested from the successful applicant 

(Use the tab key in order to move between fields. The form may then be saved and printed or emailed.)

APPLICATION FOR THE POST OF       

PLEASE ANSWER ALL THE FOLLOWING QUESTIONS AND, IF THE ANSWER TO ANY IS YES, PLEASE GIVE DETAILS.

Name                                                                                                                                                               

Address                                                                                                                       
                                                                                                                                                             
(Please tick as applicable)
 
1.	Have you suffered from any physical condition requiring attention at hospital?		YES  NO 

2.	Have you suffered from any mental condition requiring medical treatment?			YES  NO

3.	Are you currently receiving medical treatment for any conditions?		                              YES  NO
                        
4.	Is there any medical condition of which you are aware which might affect your suitability	YES  NO
       for employment?

5.	Have you ever been rejected for, or lost employment on the grounds of being considered 	YES NO   
medically unfit?

6.	Have you lost more than 5 days in the past year due to illness or accident?			YES NO   

Detail of item  (       )

                    

Signature                                                                                                       Date                                                                 

Note:	If the answer to any of the above questions is YES and the answer is not with regard to a routine matter e.g. removal of 	tonsils or appendix, child-birth, fracture of arms or legs etc., then it may be necessary for the Council's Medical Adviser to 	obtain further information from your own Doctor.  If this should be the case then please complete the section overleaf.
	
FURTHER MEDICAL INFORMATION

I have no objections to the Council’s Medical Adviser contacting my own Doctor (details below) in order to ascertain my suitability for employment in the post detailed overleaf.

Signature of  Applicant                                                                                                       Date                                                                                                            

Name of Doctor                                                                                                                                                                
Address