Health Declaration Form Template UK

The Health Declaration Form Template UK is available in several formats, including PDF, Word, and Google Docs, and features customizable and printable examples.

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Sample

Health Declaration Form Template UK

Editable – Printable

PDF – 1 PDF – 2

Health Declaration Form Template UK

1. Personal Information




2. Address Information

3. Emergency Contact Details


4. Medical History

5. Current Medications

6. Allergies

7. Health Questionnaire

Yes No

Yes No

Yes No

8. Consent and Declaration

9. Signature and Date


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Examples

Health Declaration Form Template UK (1)
Applicant’s Details:
[Full Name]
[Date of Birth]
[Address]
[Phone Number]
[Email Address]
Emergency Contact:
[Emergency Contact Name]
[Emergency Contact Phone]
[Relationship to Emergency Contact]
Health Information:
Please indicate if you have any of the following conditions:
– Allergies: [Yes/No], if yes, please specify: [Details]
– Chronic diseases (e.g., asthma, diabetes): [Yes/No], if yes, please specify: [Details]
– Recent surgeries: [Yes/No], if yes, please specify: [Details]
– Current medications: [Yes/No], if yes, please specify: [Details]
– Other health concerns: [Yes/No], if yes, please specify: [Details]
Vaccination Status:
COVID-19 Vaccination: [Yes/No], if yes, please provide date(s): [Details]
Other Vaccinations: [Specify any other relevant vaccinations and dates]
Do you have any disabilities or require special assistance?
[Yes/No], if yes, please specify: [Details]
Declaration:
I hereby declare that the information provided above is accurate and complete to the best of my knowledge.
[Applicant’s Signature]
[Date]
Health Declaration Form Template UK (2)
Personal Information:
[Full Name]
[Date of Birth]
[Nationality]
[Address]
[Contact Number]
Health History:
Have you ever been diagnosed with any of the following?
– Heart Disease: [Yes/No], if yes, details: [Details]
– Respiratory Issues: [Yes/No], if yes, details: [Details]
– Mental Health Conditions: [Yes/No], if yes, details: [Details]
– Other significant health issues: [Yes/No], if yes, details: [Details]
Medications:
Are you currently taking any medications? [Yes/No], if yes, please list them: [Details]
Allergies:
Do you have any allergies? [Yes/No], if yes, please specify: [Details]
Doctor’s Information:
[Doctor’s Name]
[Doctor’s Address]
[Doctor’s Phone Number]
Consent:
I consent to the collection and use of my health information for the purpose of [Purpose].
[Applicant’s Signature]
[Date]

Printable

PDF – 1 PDF – 2

Health Declaration Form Template UK