Health Assessment Questionnaire for Night Workers

The following medical conditions could possibly affect your health and ability to safely carry out night work, or could be made worse by night work.

Do you suffer from any of these conditions?


I certify that all the answers given above are true to the best of my knowledge and belief. I understand that no medical details will be divulged without my permission to any person outside Occupational Health, but an opinion about my fitness for night work will be issued to management.