ST ALOYSIUS’ COLLEGE

PRE-EMPLOYMENT MEDICAL FORM

CONFIDENTIAL

Date: ……………………………………….

Surname:………………………………….. First Names:………………………… Gender:……..

Questionnaire

Do you know of any health issue that would prevent you working in a standard educational environment without adjustment?	Yes/No
Are you taking any medication to suppress any contagious or infectious disease?	Yes/No
How many days sickness/absence have you had in the last year?	………..

Give further information if the answer to any of the above is YES:

The above answers are to the best of my knowledge true

…………………………………………………………………….(signed)