Bardwood Support Services | Leadership & Management

Are you registered disabled? *
Yes No

Is your eyesight, hearing or sense of smell impaired anyway?*
Yes No

Do you suffer from epilepsy? * Yes No

When was your last seizure *

When was your medication last checked

How long have you been on the same medication and dosage*

When do you take the medication

What can set off a seizure*

Who is your condition managed by?

Do you take medication on a strict timetable?
Yes No

Are you able to cope in crowded environments? *
Yes No

Are you able to work in confined spaces?
Yes No

Are you sensitive to flashing lights? *
Yes No

Are you able to work at heights and high places?
Yes No

Are you able to walk and stand for continuous periods of time? (up to 6 hours without a break) *
Yes No

* I confirm that the above details are correct to the best of my knowledge and that I will keep the company informed of any changes in my medical state that may affect my work.

Name*

Signed

National Insurance Number

Date

Medical Health Questionnaire

Welcome to BardWood Support Services

Medical Health Questionnaire

How long have you’ve been