Arizona Peace Officer Standards and
Training Board
TO THE APPLICANT: Peace officers are required to perform a variety of strenuous and difficult job functions, including those described in the job
description for entry level Arizona peace officer. A medical examination, including this form, is required by the Arizona Peace Officer Standards And
Training Board prior to appointment as a peace officer. This is to ensure that each applicant is able to safely perform these essential job functions
with or without reasonable accommodations. Complete this form prior to your scheduled physical examination as directed by the hiring agency.
First Middle Last
Numbers and Street Name City State Zip Code
SECTION A. Have you ever or do you now have any of the following? For "YES" answers, list the question number and supply full details on
page 3, the continuation sheet of this form. If the condition required hospitalization, check the corresponding box marked under
the title "HOSPITAL".
1. Head injury
21. Skin trouble
2. Back trouble or back pain
22. Any complications from childhood diseases
3. Any defects of bones or joints (including amputations,
broken bones or dislocations)
23. Sensitivity to dust
4. Pernicious anemia or leukemia
24. Other allergies
5. Rheumatism or arthritis
25. Cancer or malignancy
6. Trick or locked knee/knee injury
26. Tumor, growth or cyst
7. Foot trouble or lameness
27. Polio
8. Eye injury, surgery, or disease
28. Rheumatic fever
9. Have you ever worn glasses/contact lens
29. Heart trouble (including circulatory problems)
10. Hard of hearing or hearing problems
30. High or low blood pressure
11. Headaches
31. Varicose veins
12. Mental illness or nervous disorder
32. Diabetes or sugar in urine
13. Addiction to drugs or alcohol
33. Colitis
14. Fainting, dizzy spells, or epilepsy
34. Gall bladder trouble
15. Hepatitis, jaundice, or liver ailment
35. Kidney or bladder trouble
16. Disorder of the nervous system
36. Hemorrhoids or piles
17. Tuberculosis or lung disease
37. Rupture or hernia
18. Shortness of breath, asthma or bronchitis.
38. Mononucleosis
19. Any type of blood disorder
39. Any contagious disease
20. Any sleeping problems.
40. Any immune system disorder
AZ POST Form MH (June 2011) Page 1 of 3
Print Applicant Name:
Continued - Answer the following questions. For "YES" answers, list the question number and supply full details on page 3, the
continuation sheet of this form.
41. Have you ever had or been advised to have an operation?
42. Have you ever been a patient (committed or voluntary) in a mental hospital?
43. Have you ever had any other illness, injury, or physical condition not named on this form other than childhood diseases
or minor illnesses?
44. Are you presently under a doctor's care for any condition?
45. Have you taken any medication during the last 12 months?
46. Do you have any physical or emotional limitations?
47. Do you smoke? If "YES", place the number of packs per day in the following blank:
48. Do you drink? If "YES", place the number of drinks per week in the following blank:
PHYSICIANS CONSULTED: (For any of the questions answered "YES", identify the question number and physician below.)
Telephone #
(Include area code)
(street, city, state, zip code)
List all illegal drugs or controlled substances you have ever used to treat or alleviate the symptoms of a medical condition. This includes
marijuana and other controlled substances as well as prescription drugs or medications that were not prescribed for you. (Use page 3, the
continuation sheet as needed OR directed below).
On page 3, the continuation sheet of this form please list the following for each drug(s) or controlled substance(s) that you listed above:
Was the use prescribed or recommended by a physician or health care provider? If yes, list the names, address and telephone number of each physician or
health care provider who prescribed or recommended the drug or controlled substances.
List the date of the first and last use of the drug or controlled substance.
Describe every way you obtained the drug or controlled substance.
Describe the character of use; include methods of ingestion, location, dosages, frequencies, persons present or those persons with knowledge of the use.
Describe why you stopped using it, if applicable.
State any other factors you believe are relevant to a discussion of your medical condition or the propriety of your drug or controlled substance use.
Other than to actually treat the medical condition, describe any uses of the drug or controlled substances.
I hereby authorize the above listed physician(s) to release any and all medical information to the hiring agency, Arizona POST, its staff or designated
_______________________________________________________ ___________________________
Signature of Applicant (Sign in Ink) Date
PENALTY: Any falsification, withholding information or failure to answer all questions completely and accurately may cause forfeiture of eligibility.
CERTIFICATION: I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and answers to
the questions, and that all statements and answers are true and correct to the best of my knowledge and belief. I further agree to take any future
physical examinations the hiring agency or Arizona POST may deem necessary.
_______________________________________________________ ___________________________
Signature of Applicant (Sign in Ink) Date
AZ POST Form MH (June 2011) Page 2 of 3
Arizona Peace Officer Standards and
Training Board
Continuation Sheet
Please state the applicable question number for each entry made on this page. Use the space provided to complete
answers for previously asked questions or for necessary explanation and clarification.
AZ POST Form MH (June 2011) Page 3 of 3