ADVANTAGE ANGELS – HEALTH QUESTIONNAIRE

Full Name

Gender Gender Male Female Non Binary

Marital Status Marital Status Single Partnered Married Separated Divorced Widowed

Childhood Illness (tick all that apply) Childhood Illness (tick all that apply) Measles Mumps Rubella Chicken Pox Rheumatic Fever Polio

Immunisations (tick all that apply) Immunisations (tick all that apply) Tetanus Hepatitis Influenza COVID-19 Pneumonia Chicken Pox MMR Tuberculosis

List any medical problems that have been diagnosed that may affect your ability to work:

List any long-term medications that you are prescribed that may affect your ability to work:

Next Of Kin - Name

Next Of Kin - Address

Next Of Kin - Contact Number

Next Of Kin - Relation To You