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Company number: 02665898
Registered address: Unit A Telford Court, Chester Gates Business Park, Chester, England, CH1 6LT

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Step Two

Health questionnaire

Please complete this night work health assessment as part of your onboarding. Answer each question honestly. If you select Yes, provide details in the box that appears below.

URL

This field is for validation purposes and should be left unchanged.

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?(Required)

Yes

No

If yes, please provide details

Have you had any medical problem in the past that has prevented you from working at night?(Required)

Yes

No

If yes, please provide details

Have you ever had any illness/impairment/disability which may have been caused or made worse by work?(Required)

Yes

No

If yes, please provide details

Are you having, or waiting for treatment (including medication) or investigations at present?(Required)

Yes

No

If yes, please provide details

Have you had any surgery in the last 12 months?(Required)

Yes

No

If yes, please provide details

Are you diabetic?(Required)

Yes

No

If yes, please provide details

Are you subject to angina, or other heart problems that may affect your fitness?(Required)

Yes

No

If yes, please provide details

Have you had duodenal or stomach ulcers in the past, or are you under treatment for those at present?(Required)

Yes

No

If yes, please provide details

Have you had any continuing bowel problem, for instance following major surgery?(Required)

Yes

No

If yes, please provide details

Do you have any chronic chest problems such as asthma, emphysema or bronchiectasis?(Required)

Yes

No

If yes, please provide details

Do you have epilepsy or any condition causing loss of consciousness or impaired awareness?(Required)

Yes

No

If yes, please provide details

Have you had any hospital admissions in the past 12 months?(Required)

Yes

No

If yes, please provide details

Have you ever had chicken pox or shingles?(Required)

Yes

No

If yes, please provide details

Do you need any adjustments or assistance to help you do your job?(Required)

Yes

No

If yes, please provide details

Do you take any prescribed medication?(Required)

Yes

No

If yes, please provide details

Are you taking any medication to a strict timetable?(Required)

Yes

No

If yes, please provide details

Does any of your medication cause drowsiness or affect alertness?(Required)

Yes

No

If yes, please provide details

Do you have any disability affecting mobility that will cause difficulties in arranging night work?(Required)

Yes

No

If yes, please provide details

Do you have any recurrent or continuing sleep disturbance requiring medical advice?(Required)

Yes

No

If yes, please provide details

Do you have any visual impairment that could affect safe working at night?(Required)

Yes

No

If yes, please provide details

Do you have caring responsibilities that may be affected by working nights?(Required)

Yes

No

If yes, please provide details

Do you have difficulty with transport to/from work during night hours?(Required)

Yes

No

If yes, please provide details

Declaration

I confirm that the information I have provided in this assessment is true and complete to the best of my knowledge. I understand that any relevant omission or false statement may affect my onboarding, placement suitability, or continued engagement.

Consent(Required)

I confirm that the information above is true and complete.

Signature(Required)

Full name(Required)

First Last

Phone number(Required)

Email address(Required)

Date(Required)

DD dash MM dash YYYY

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With over 30 years’ experience, we provide personalised care and support that helps people live the lives they choose, promoting independence, comfort and meaningful everyday moments.

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Company information

Modern Slavery Compliance Statement
Gender Pay Gap Report - March 2026
ENS Care and Support Ltd - CRP PPN 06-21
Registered address: Unit A Telford Court, Chester Gates Business Park, Chester, CH1 6LT
ENS Care & Support is part of the Bluestones Investment Group

Copyright © 2026 ENS Care & Support | All rights reserved

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