On employment questionnaire - Centrica MyHealth Step 1 of 6 16% Important information before you startThe purpose of this questionnaire is to establish your fitness for the job for which you have applied. The information supplied by you will remain confidential to the Company and will be used (i) to assess your medical capability to do the job for which you have applied; (ii) to determine whether any reasonable adjustments may be required to accommodate any disability or impairment which you might have; and (iii) to ensure that none of the requirements of the job, for which you have applied would adversely affect any pre-existing health conditions you may have.It is important that your answers are complete and accurate and you will be asked to sign a declaration indicating that you have answered the questions truthfully to the best of your knowledge.You may be asked to participate in a medical assessment. This may be due to a query on the questionnaire, statutory reasons, or a best practice approach to the management of your health at work. This questionnaire may also be used by medical personnel to help you manage your health in the future and to help protect you from any occupational and non-occupational health risks.It should be noted that this questionnaire is only to assess your fitness for the position for which you have applied. Should you apply for a different position in the future, you may be asked to complete a further questionnaire. This Medical Declaration is designed to be used for:• An assessment of your health at the point you commence work, so that any potential health issues may be considered for compliance with Health and Safety or Equality Legislation.• An assessment at the point that you may change your role at work to ensure that any new health issues are also reviewed for compliance with Health and Safety and Equality Legislation. HiddenEmployer Pass through testCentricaMyHealthAbout youName* First Last Address* Street Address City County Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Best contact number* Email address* Job title* Employee ID Number* AssessmentThese questions are designed to comply with Health and Safety legislation and the Equality Act. Please complete the following 6 questions to enable us to assess whether you will require any modifications to the various tasks within your job role either now or possibly in the future.1. Have you at any time suffered from any chronic/long-term medical condition or is there any other known disability, abnormality, or recurrent illness or injury?* Yes No Please give further details (e.g. treatment (including dates), future treatment, medication, special requirements)*2. Have you had an in-patient stay in hospital within the last five years?* Yes No Please give further details (e.g. treatment (including dates), future treatment, medication, special requirements)*3. Have you had a consultation, diagnostic test or outpatient treatment within the last three years?* Yes No Please give further details (e.g. treatment (including dates), future treatment, medication, special requirements)*4. Have you had a consultation with a General Practitioner and/or prescriptions for any drugs or medication within the last two years?* Yes No Please give further details (e.g. treatment (including dates), future treatment, medication, special requirements)*5. Do you have any known or foreseeable need to consult any doctor or other health professional?* Yes No Please give further details (e.g. treatment (including dates), future treatment, medication, special requirements)*6. Are you aware of any condition that may impact on your ability to perform certain tasks and which therefore may require an assessment of what modifications to your duties needs to take place?* Yes No Please give further details (e.g. treatment (including dates), future treatment, medication, special requirements)* Are you a driver of a company car or liveried vehicle? Yes No As far as you know do you have any health problems (including visual problems) which could interfere with your ability to drive or affect your driving safety? Yes No Do you suffer from any medical condition which you have been required to declare to the DVLA or had your driving licence withdrawn? Yes No Please indicate date of your last opticians test:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Lifestyle (optional)Completing this section of the questionnaire will not affect the outcome of your assessment. However, the information provided will enable us to support your health and wellbeing in the future.Height (cms) Weight (kgs) Smoker No Yes How many (per day) Alcohol (per week)One alcohol unit is measured as 10ml or 8g of pure alcohol. This equals one 25ml single measure of whisky (ABV 40%), or a third of a pint of beer (ABV 5-6%) or half a standard (175ml) glass of red wine (ABV 12%). You can work out your alcohol units with this handy sum: Strength (ABV) x Volume (ml) divided by 1000 = No. of units 0 Units < 5 Units 6 - 10 Units 11 - 15 Units 16 - 20 Units 21 - 25 Units 26 - 30 Units > 30 Units How much physical activity do you do (per week)?Physical activity counts when your heart rate and breathing are elevated, so that you begin to sweat and are slightly out of breath for extended periods of time i.e. over 10 minutes 0-1 hours 1-2 hours 2-3 hours 3-4 hours 4+ hours DeclarationPlease read this declaration carefully before submitting: I declare that all foregoing statements are true to the best of my knowledge. I accept that in the event of my being employed and it subsequently being shown that medical information has not been disclosed by me or it have been misleading or false, I may become liable to disciplinary proceedings. I understand that I may be required to attend for consultation with a healthcare rm case manager or that I may be required to undergo a medical examination.Information for applicantsData Protection Lawhealthcare rm will treat the information you provide on this form in a strictly confidential manner and it will be held in accordance with the principles of medical ethics and relevant legislation. If you require reasonable adjustments to your job and workplace (e.g. for reasons of health and safety) and/or where any such adjustment is necessary for your personal protection (e.g. epilepsy, type 1 diabetes, functional disability), information about the adjustments required (but not your underlying medical condition) may be divulged to your employer for the purpose of determining whether any adjustments are required or can be made to the post for which you have applied.Equality Act 2010 (Disability)This form enables healthcare rm to assess your medical fitness against the specific requirements of the post for which you are being considered. If you have a disability or impairment, the information you give us about it on this form will help us to ensure that any reasonable adjustments you may require are considered properly. The information you give us will also provide baseline data for any future health assessment(s) that may be made during your employment.Contact AddressIf you have any questions please write to healthcare rm, Ashvale, Ashchurch Business Park, Alexandra Way, Tewkesbury, Gloucestershire, GL20 8NB or email to ost@healthcare-rm.comI confirm my agreement with the above declaration* Please tick here CAPTCHA