Health Declaration Form

Circulatory problems such as thrombosis or varicose veins

High blood pressure

Heart Trouble

Asthma

Epilepsy/fits

Frequent migraine headaches

Persistent cough

Any condition that affects your eyesight in any way (after lens correction)

Any condition that affects your hearing in any way

Dermatitis, eczema, psoriasis or any skin allergies or other problems

Any condition that affects your physical ability (i.e. stamina, walking, balance, bending, kneeling, or manual handling)

Any condition that may impair your consciousness, make you black out, lose concentration, or become confused or disorientated

Bipolar disorder, anxiety, panic attacks or stress related

Any eating disorders, alcohol or drug dependency or misuse

Arthritis or joint problems

Allergies of any kind

Depression

Diabetes

Rheumatic

Any condition causing excessive drowsiness or severe pain

Do you have any other medical condition that would affect your ability to work within the care industry?

Are you taking any regular medication to treat any existing medical conditions that you would be required to take to work?

To the best of my knowledge and belief, the information given above is correct. I consent under the Data Protection legislation to the company processing the information I have provided on this Questionnaire for the purpose of assessing my health and suitability for employment. I understand and agree that the information will be retained for as long as the company deems necessary and that information may be passed to a third party such as a Medical Assessor for comments.

Date

Time

IP Address

By submitting this form, you consent to the collection of your IP address, date, and time of submission. BC CARE LTD will use this information for the sole purpose of verifying your submission and ensuring compliance with our company's policies and legal requirements. The data collected is protected under the Data Protection Act 2018 and the General Data Protection Regulation (GDPR) and will only be used in accordance with these laws. BC CARE LTD is committed to maintaining the highest standards of privacy and data security. If you have any concerns about how your data is handled, please contact us directly.

Mon - Fri:	8:00 am - 8:00 pm
Saturday:	9:00 am - 6:00 pm
Sunday:	CLOSED

Visiting Hours

Health Declaration Form

Health Declaration Form

About Us

0113-824-1978

contact@bc-care-ltd.co.uk

Visiting Hours