Smyths Toys Warehouses – Pre-Start Annual Health Assessment Do you suffer or have you ever suffered from any of the following conditions?Any form of heart condition? (e.g., angina, heart attack, heart or chest pain requiring specialist attention?* Yes No Diabetes or glandular trouble?* Yes No Gastric, duodenal, or peptic ulcer, heart burn, hiatus hernia, or other stomach disorder?* Yes No Migraines, blackouts, fits, fainting attacks, epilepsy, narcolepsy, or diseases causing excessive or distributed sleep?* Yes No Any disorder requiring strict attention to time at which treatment must be taken?* Yes No Any disorder that might affect your ability to undertake night work?* Yes No If you answered “yes” to any of the above questions, please give full details of your condition to your line manager.Declaration* I certify that the above given information is to the best of my knowledge. I understand that any changes to my health condition during my employment I will need to notify my line manager. If necessary, you may need to undergo examination by the company medical advisor.Employee Name* First Last Employee Email Address* Employee Signature*Date* DD slash MM slash YYYY Δ
