Disability & Health Questionnaire – A M Water Services Forms

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AMWS — Disability & Health Questionnaire (HR_FM_02)

Confidential health questionnaire — completed at onboarding and updated annually or as conditions change. Used solely to support reasonable adjustments and occupational health.

Document Reference	HR_FM_02 — Disability & Health Questionnaire
Issue Number	2
Issue Date	12 May 2026
Next Review	12 May 2027
Controlled By	Sean Ashton (HSQE Consultant, Onyx Operations)
Approved By	Aaron Mason, Managing Director
Status	Legacy XLSX retired on digital go-live.

Employee / sub-contractor name(Required)

Date completed(Required)

Disability

Do you consider yourself to have any long-standing illness or disability that may affect your work?(Required)

Yes

If yes — please give details and any reasonable adjustments that would help

Health questionnaire — have you suffered or do you suffer from any of the following?

All information is treated confidentially. Tick Yes for any condition that applies.

Diabetes

Yes

Heart disease

Yes

High blood pressure

Yes

Stomach or intestinal disorders

Yes

Chronic chest disorders

Yes

Vibration White Finger (HAVS symptoms)

Yes

Back problems

Yes

Epilepsy

Yes

Colour blindness

Yes

Deafness / hearing impairment

Yes

Dyslexia

Yes

Any medical condition requiring medication to a strict timetable

Yes

Stress or anxiety

Yes

Any condition which causes difficulties sleeping

Yes

Any allergies

Yes

General health questions

Have you ever had an illness which caused you to be absent from work for more than 30 days?

Yes

Have you ever had to give up any previous job for medical reasons?

Yes

Do you wear spectacles / contact lenses?

Yes

Do you smoke?

Yes

Weekly consumption of alcohol (in units)

Please enter a number from 0 to 200.

Any other relevant health information

Sign-off

Signature(Required)

Email(Required)