Hepatitis? Yes No
Typhoid or Paratyphoid? Yes No
Persistent Cough? Yes No
Diarrhoea or Vomiting lasting for more than 24 hours? Yes No
Recurrent boils or septic fingers? Yes No
Infected or discharging ears? Yes No
Skin conditions e.g. dermatitis etc? Yes No
Other septic infections, including recurrent infections of the mouth, nose, throat or eye? Yes No
Have you visited you dentist within the last 12 months? Yes No
I have answered each question, to the best of my knowledge and belief. I am aware that the Company reserves the right to have me examined by a Doctor or Specialist nominated by the Company. I understand that deliberate omissions/false information will lead to the termination of any employment undertaken.
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