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Funding
Apply for funding
Established agency funding
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Medical questionnaire
Send medical questionnaire to worker
Please complete this form to send a medical questionnaire to one of your workers. When they complete the questionnaire, the final document will be emailed back to RFS and kept on record for the worker.
Worker details
Name
(Required)
First
Last
Email
(Required)
Agency details
Agency name
(Required)
Agency email address
(Required)
Medical questionnaire
Please complete this medical questionnaire. A copy of your completed questionnaire will be securely sent to Recruitment Funding Solutions.
Agency details
Agency name
Agency email address
Worker details
Name
(Required)
First name
Last name
Worker email address
(Required)
Your address
(Required)
Street Address
Address Line 2
City
County
Postcode
Medical questions
Has your doctor ever said your blood pressure was too high or too low?
(Required)
Yes
No
Please provide details
(Required)
Do you have any known cardiovascular problems (abnormal ECG, previous heart attached, etc.)
(Required)
Yes
No
Please provide details
(Required)
Has your doctor ever told you that your cholesterol was too high?
(Required)
Yes
No
Please provide details
(Required)
Have you (or a family member) ever been told that you have diabetes?
(Required)
Yes
No
Please provide details
(Required)
Do you have any injuries or orthopaedic problems (back, knees, etc.)?
(Required)
Yes
No
Please provide details
(Required)
Do you have stiff or swollen joints?
(Required)
Yes
No
Please provide details
(Required)
Do you have tension or soreness in any area?
(Required)
Yes
No
Please provide details
(Required)
Are you taking any prescribed medicine or dietary supplementation?
(Required)
Yes
No
Please provide details
(Required)
Do you ever have problems sleeping?
(Required)
Yes
No
Are you pregnant or post-partum (< 6 weeks)?
(Required)
Yes
No
Have you ever been advised by a doctor, physician, or specialist not to perform any type of exercise / activity?
(Required)
Yes
No
Please provide details
(Required)
Do you have any other medical condition, injury, or anything else we should be aware of that we have not yet mentioned?
(Required)
Yes
No
Please provide details
(Required)
Name
This field is for validation purposes and should be left unchanged.
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