medical information

Please describe any medical conditions which may affect you when you're at work. This means anything that medical professionals might need to know, if something happens and you need immediate treatment. Please give names and contact details of your doctors and what their medical service is - e.g. GP, type of specialist. We also need the names of a few personal contacts in case your primary contacts aren't available and we need to let someone know what's happened.


You are under no obligation to provide personal health information to EveryMan. Completing this form is completely voluntary.


So we know for sure, please :

  • check the 'I don't wish to provide my personal medical information to EveryMan' box below,
  • check the the 'Decline' option in the following question, and


Leave the rest of the form blank if you don't have medical conditions or don't want to tell us about them.

Do you have any medical conditions?

Medical conditions, medication etc.

Please list medication name and dosage, e.g. Atorvastatin 80mg

Medical contacts

Name, phone number, address, type of doctor

Personal contacts

people you want contacted in case of emergency. Please list in order of priority, so the last ones in the list are people we could contact if your main contacts aren't available.

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