Portsmouth Lone Care Services

If the answer is yes to any of the questions in this section, please give full details in the space provided at the bottom including dates, duration, and outcome of the illness or condition. If Lone Care Services Ltd has concerns about your fitness to work, any offer of work may be subject to a satisfactory medical report. On occasion we may ask your permission to liaise with your GP or a medical specialist for further information.

Please note: you must inform your local office immediately if your health changes significantly / or condition identified on the form occur / alter. Equally should you develop a health condition not identified on this form then by signing below you acknowledge the requirement to notify us of such.