Visitors and Contractors Health Questionnaire

Are you now, or have you suffered in the last 7 days from any of the following:
Declaration

Contractor?

Skin Disease (eczema, dermatitis, psoriasis)

Stomach or bowel disorders

Jaundice or Hepatitis

Food poisoning symptoms

Hearing loss/discharging ears

Fits, blackouts, migraines

Productive cough and/or sneezing

A Food Allergy of any type

If YES, please state what allergy you are sensitive to

Have you been outside of the UK in the last 3 months?

If YES, where?

If YES, did you have to seek medical advice for any food poisoning symptoms?

Have you been in contact with anyone who is/has been suffering with any of the above within the last 48 hours?

Have you ever had or are you known to be a carrier of typhoid or paratyphoid?

Have you visited another food premises today?

If YES, what products were they handling?

I declare that

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carrying recording or photographic equipment

If you are carrying recording or photgraphic equipment, please state what type here

I declare that

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carrying any personal medication

If you are carrying personal medication please state what type here

I declare that

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carrying any allergens on my person or belongings

If you are carrying an allergen(s)t, please state which allergen you are carrying; a complete list can be found via the below link

By clicking this box, I declare that to the best of my knowledge, the information given in this document is true and accurate. I do not suffer from  any illness or disability, which is likely to cause a food safety or a health and safety hazard.

QMCVHQ

Feb 19

Version 2.2