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Call: 0333 1234 530
info@entrustsc.co.uk
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Health Check
Health Check
Name
Date
Please indicate whether you have suffered or had problems relating to the following
Select where applicable
Allergies
Back/joint problems
Bronchitis/Asthma
Diabetes
Epilepsy/blackouts
Heart Disease
Hepatitis B
Migraine
Typhoid
Tuberculosis
Ulcers
Any other condition
If you selected any of the above, please give details
Please select if you have had the following inoculations
BCG (Tuberculosis)
German Measles
Hepatitis B
Polio
Tetanus
None/unknown
Please select if you have had any illness associated with or contact with
MRSA
Any infectious disease
Any serious physical or mental illness
Any surgery that would influence work practice
If you selected any of the above, please give details
Please use this section for any additional information
Are you currently under a GP for any medical condition?
Yes
No
Are you a smoker?
Yes
No
Please confirm if you have received COVID vaccinations
Yes
No
Exempt
Dates
Dates
Consent for storing submitted data
Yes, I give permission to store and process my data
By submitting this application it is the equivalent of an e-signature
I confirm that I am signing by submitting
Our address
Entrust Social Care Ltd
International House
Stubbs Gate
Newcastle-under-Lyme
Staffordshire
ST5 1LU
Phone: 0333 1234 530
info@entrustsc.co.uk
We are an equal opportunities employer
Application
Equality & Diversity Monitoring
Confidentiality Agreement
Timesheets
