DC-004a Health Questionnaire
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Regulation 21 of the Health and Social care Act 2008 (Regulated Activities) (Amendment) Regulations 2015 states that a person employed for the purposes
of carrying on a regulated activity must be physically and mentally fit for that work.

Please answer the following questions

2. Have you ever suffered from: Allergies, eczema, dermatitis or other skin troubles? *
Question 2
3. Do you suffer from: Epilepsy, migraine, asthma, angina, heart trouble or any condition requiring long-term medical help or a strict medication timetable? *
Question 3
4. Have you ever suffered from: Mental illness including anxiety, depression or nervous debility? *
Question 4
5. Have you ever required treatment for: Hernia or rupture, rheumatism, back problems, slipped disc, sciatica or Repetitive Strain Injury (RSI)? *
Question 5
6. Do you suffer from: Diabetes, ulcers, stomach or other intestinal disorders? *
Question 6