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Medical Questionnaire
Do you suffer or have you ever suffered from any of the following physical problems? *
Do you currently or have you ever suffered from any vision impairments/hearing difficulties as follows? *
Have you ever had any of the following lung problems? *
Have you ever had any of the following cardio vascular problems? *
Do you suffer from any of the following skin problems? *
Do you or have you ever suffered from any of the following? *
Do you or have you ever suffered from any of the following? *
The above are true and accurate answers to the questions asked. I confirm that the information given on this form is true and complete. I am aware that any false, misleading or incomplete information given may result in the termination of my employment. I agree and I am aware that this document may be copied to a perspective employer.

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N.I. Office

15 Georges Street, Dungannon, BT70 1BT

T:028 87 440033 E: info@haugheyrecruitment.com

Swords Office

Unit B2 Metropoint Business Park, Kettles Lane, Swords, Co Dublin

T: 01 649 8511 E: info@haugheyrecruitment.com

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