MCare NI

Annual Health Declaration Form

Annual Health Declaration
Are you a registered disabled person?
Are you willing to undergo a medical examination (if required)?

Below are questions about your past and present state of health, all questions are to be answered by using the YES / NO boxes. Where answering YES, Please provide further details in the box provided.

Have you ever suffered from, or do you currently suffer from, any of the following?

1. Back pain, disc trouble, rheumatism, arthritis, gout:
2. Dermatitis, eczema, or other skin disorders:
3. Any form of alcohol or substance dependency:
4. Epilepsy, fainting attacks, or black outs:
5. Palpitations, shortness of breath, chest pain:
6. High blood pressure, or, any other ailment of the heart, lungs, Chest or circulatory system:
7. Mental Health Issues e.g. Depression, anxiety or other:
8. Any visual or hearing defects:
9. Diabetes, anaemia, or, any blood or gland disorder:
10. Rheumatic fever, or any joint / muscular problems:
11. Recurring headaches:
12. Ulcers, gall stones, or any ailment of the intestines or liver:
13. Any known allergies:
14. Any other illness not referred to above:
15. Do you use/take any prescribed or none prescribed drugs:
16. Do you have any other pre-existing health related condition that would impact on your ability to work in regulated activity?

Please provide details of all absences from work due to illness or injury during the last year

Reason for absence (include the number of days you where absent for):