Print Applicant Name:
SECTION A.
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.
QUESTION
YES NO
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.)
DATE ITEM PHYSICIAN
Telephone #
(Include area code)
ADDRESS
(street, city, state, zip code)
SECTION B:
ILLEGAL DRUGS or CONTROLLED SUBSTANCES:
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
representatives.
_______________________________________________________ ___________________________
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
