Coral Leisure Wicklow Employee Pre-Return Work Health Questionnaire
Name
First Name Last Name
Date of birth
Month Day Year
Date
Email
example@example.com
Place of Work
Job Title
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number
Area Code Phone Number
Doctors Name
First Name Last Name
Doctors Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code

Please complete this form to the best of your knowledge and tick the appropriate box(es). Please note that ticking “yes” does not necessarily mean you cannot work, simply that we may need further information*

	Yes	No
Are you on a permanent shift?
Do you suffer from diabetes?
If yes, do you require insulin injections?
Do you suffer from a heart condition or a circulatory (blood, artery, or vein) disorder?
If yes, does this affect your physical stamina and your ability to do physical work?
Do you suffer from any stomach or intestinal disorder such as ulcers?
Do you have any condition where the timing of a meal is particularly important?
Do you suffer from any medical condition which affects your sleep?
Do you suffer from a chronic chest disorder (such as asthma) where night-time symptoms are particularly troublesome?
Do you suffer from any medical condition requiring regular medication at strict times e.g. epilepsy or thyroid disease?
Have you had depression, "stress", nervous disorders, alcohol or drug addiction or other mental health conditions, in the last two years?
Are you aware of any other health factors that may affect your fitness to carry out night work or do you feel night shifts affect your health in any way?
Do you have any allergies?
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?
Have you been diagnosed with confirmed or suspected Covid-19 infection in the last 14 days?
Are you in close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)?
Have you been advised by a doctor to self-isolate at the time?
Have you been advised by a doctor to cocoon at this time?

Please use the space below for any additional comments, particularly where you have answered "yes" to any question:
Declaration
I certify that the answers to the above questions are correct to the best of knowledge and belief.
Employees Signature*
Clear
Name*
First Name Last Name
Date*
Month Day Year
Date
Should be Empty:

Coral Leisure Wicklow Employee Pre-Return Work Health Questionnaire