Health Declaration FormLydian CareHealth Declaration FormFor candidates to submit their health declaration form online.Health Declaration - ConfidentialPlease complete this form accurately and honestly.Name First Last Date Form Completed:(Required) DD slash MM slash YYYY Gender(Required)MaleFemaleOtherPlease select your gender.Your Date of Birth:(Required) DD slash MM slash YYYY Role Applied:(Required)Homecare Worker - Care in the CommunityHealthcare Assistant - Hospital or PrivateOtherPlease select which role you have applied for.1. Do you have, or have you ever had, any medical conditions or operations?(Required) Yes NoPlease provide detail:(Required)2. Are you receiving any pills/tablets, injections, or other treatment, at the moment? (including pills, tablets, inhalers, injections, self-medication, physiotherapy, psychotherapy etc)(Required) Yes NoPlease provide detail - including any medication you are taking and the prescribed dose:(Required)3. Have you ever suffered a work-related illness, or given up work because of ill health?(Required) Yes NoPlease provide detail:(Required)4. Have you ever had any physical limitation? (including vision or hearing)(Required) Yes NoPlease provide detail:(Required)4.1 Has there been /might there be an effect on your ability to work?(Required) Yes NoPlease provide detail:(Required)5. Have you ever had any kind of back, joint or muscle problem?(Required) Yes NoIf yes, did it lead to time off work?(Required)6. Have you ever had any mental illness? (including anxiety, depression, self-harm, eating disorders, psychological or emotional problems)(Required) Yes NoPlease provide detail:(Required)6.1 Has there been /might there be an effect on your ability to work?(Required) Yes NoPlease provide detail:(Required)7. Have you ever had a drug or alcohol problem?(Required) Yes NoPlease provide detail:(Required)7.1 Has there been /might there be an effect on your ability to work?(Required) Yes NoPlease provide detail:(Required)Have you ever had, or do you currently have any problems with the following? You may have already entered some of this information above - If you answer yes to any of the below, please provide some brief information.8. A mental health condition that required/requires hospital treatment and/or drug treatment (e.g. Depression, Anxiety, Schizophrenia, Bipolar,)(Required) Yes NoPlease provide detail:(Required)9. A chest complaint, breathing, pain, or condition requiring hospital treatment, surgery or drug treatment (e.g. TB, Cancer, Asthma, Heart condition, High Blood pressure)(Required) Yes NoPlease provide detail:(Required)10. Migraines, Epilepsy, Blackouts, or Vertigo - requiring hospital treatment and or drug treatment (e.g. Fits, headaches, dizziness/neck pain)(Required) Yes NoPlease provide detail:(Required)11. Back Pain or Arthritis/Spinal Problems/Muscular - requiring hospital treatment and or drug treatment (e.g. Rheumatoid Arthritis/Osteoarthritis)(Required) Yes NoPlease provide detail:(Required)12. Eyesight or Hearing Problems (e.g. Do you wear glasses or hearing aids)(Required) Yes NoPlease provide detail:(Required)13. Stomach, Kidney or Bowel condition requiring hospital treatment or drug treatment (e.g. Colitis, Pancreatitis, IBS Diverticular disease, Cancer, Gall bladder problem, Hernia)(Required) Yes NoPlease provide detail:(Required)14. Diabetes, thyroid or glandular conditions requiring hospital treatment and or drug treatment(Required) Yes NoPlease provide detail:(Required)15. Allergies/Skin disorders requiring treatment (for e.g. Skin diseases, Psoriasis, Eczema, MRSA)(Required) Yes NoPlease provide detail:(Required)16. Infectious/Contagious diseases requiring any kind of treatment (for e.g. Diarrhoea, HIV Aids)(Required) Yes NoPlease provide detail:(Required)17. Do you have any health issues not covered by this form you would like to inform us of:(Required) Yes NoPlease provide detail:(Required)18. Have you had surgery in hospital in the past 2 years?(Required) Yes NoPlease provide detail:(Required)19. Are you a hospital outpatient receiving treatment?(Required) Yes NoPlease provide detail:(Required)20. How many days have you taken in sick leave in the past 2 years?(Required)14. Have you been vaccinated for any of the following:Tuberculosis/ BCG:(Required) Yes NoCOVID 19 Vaccine:(Required) Yes No1st COVID-19 Vaccine Date:(Required) DD slash MM slash YYYY 2nd COVID-19 Vaccine Date: DD slash MM slash YYYY COVID 19 Booster Date: DD slash MM slash YYYY Vaccination Card Drop files here or Select filesMax. file size: 496 MB.Please take a photo and upload your vaccine cards here.Varicella:(Required) Yes NoHave you ever had chicken pox?(Required) Yes NoMMR (Measles, Mumps and Rubella):(Required) Yes NoTetanus: inclusive of (Dip/Tet/Polio x 5:(Required) Yes NoHepatitis B:(Required) Yes NoIt is your responsibility to inform your Manager immediately if any of the above changes.Certify(Required) I certify that the information I have provided is accurate and that I am in good health and fit to carry out the duties as described in the job description in relation to the role I am applying for.Signature(Required)Please either draw your signature in the box above or use your finger or stylus if on a touchscreen device.TO BE COMPLETED BY GPDoes the candidate have a BCG scar providing evidence of receiving their BCG vaccination.YESNOHas the candidate been administered the required vaccinations based on their submitted vaccination record to work on NHS/Hospital sites.YESNOIn my professional opinion based on the information provided I declare the above-named candidate fit to work as a provider of health care in the capacity as a healthcare assistant.YESNODoctor’s Signature: Doctor’s/ Clinic Stamp Print Name: Date:
