Page 1 F-1(LE) Rev. 6/11
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax (919) 779-8210
MEDICAL HISTORY STATEMENT Form F-1(LE)
(Rev. 6/11)
This information is for official use only and will not be released to unauthorized persons.
Payment for services rendered is the responsibility of the hiring agency or the individual.
The Criminal Justice Standards Division is NOT responsible for payment.
Mail form to hiring agency or individual
DO NOT mail form to Criminal Justice Standard Division
Instructions:
To be completed by applicant for a certifiable position prior to the physical examination and presented to the examining qualified
medical professional (Physician, Physician’s Assistant, or Nurse Practitioner licensed to practice medicine in North Carolina), or
Physician and/or Surgeon authorized to practice medicine in accordance with the rules and regulations of the U.S. Armed Forces,
at the time of examination [12 NCAC 9B .0104(a)]. All questions must be answered completely and accurately. The original or a
copy must be retained in personnel files by the appointing agency.
Date: _____________________
Name: _________________________________________________________ Date of Birth: _____________________
Last First Middle
Address: ____________________________________________________________________________________________
City: ___________________________________ State: ___________________ Zip Code: _____________________
Telephone: ___________________________________ Last 4 Digits of SSN: ______________________________
Current Medications
Prescription Medications: (Include pain relievers, birth control pills, etc.)
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Over the Counter Medications: ( Include all cold allergy, headache, vitamins, supplements, herbal remedies, etc.)
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Allergies
Drug Allergies: (Include your reaction to the mediation)
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All Other Allergies: food, insects, seasons, animals, materials, etc. (Include reaction)
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Page 2 F-1(LE) Rev. 6/11
Past Medical History
List ALL hospitalizations and operations since childhood:
(Include type of surgery, date of surgery, any complications or other significant information)
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Have you EVER, in your life, had any of the following types of medical problems? [check all that apply to you]
1. CANCER: any type of cancer including skin cancer, breast cancer, and leukemia?
2. MAJOR INFECTIOUS DISEASE: such as tuberculosis, hepatitis, HIV/AIDS, rheumatic fever and others?
3. NEUROLOGICAL PROBLEMS: such as seizure disorder, stroke, concussion, severe headache, skull fracture,
recurrent vertigo, balance problems, encephalitis, meningitis, tremors, multiple sclerosis, Huntington=s chorea,
peripheral neuropathy and others?
4. PSYCHOLOGICAL PROBLEMS: such as depression, manic episodes, psychotic episodes, post traumatic
stress disorder and others?
5. EYE PROBLEMS: such as eye injury, color blindness, poor night vision (night blindness), glaucoma,
blindness in one or both eyes, very poor vision when not corrected and others?
6. EAR PROBLEMS: such as ear injury, chronic ringing (tinnitus), chronic or long lasting ear infection,
Meniere=s disease, moderate to severe hearing loss in one or both ears and others?
7. NOSE PROBLEMS: such as nose injury, allergies, nasal bleeding, loss of sense of smell, chronic or long
lasting infections and others?
8. MOUTH OR THROAT PROBLEMS: such as injury, major dental work, any kind of speech defect, chronic
or long lasting infections, abnormality of nose, mouth or throat that would interfere with wearing a respirator
and others?
9. LUNG PROBLEMS: such as asthma, emphysema, chronic or recurrent bronchitis, pneumonia, tuberculosis or
lung abscess and others?
10. HEART AND CIRCULATION PROBLEMS: such as heart murmur, heart disease, heart attack, hypertension
(high blood pressure) irregular rhythm, valve abnormalities, varicose veins, phlebitis, peripheral vascular
disease, Raynaud=s disease and others?
11. DIGESTIVE SYSTEM PROBLEMS: such as any kind of ulcer disease, hepatitis or liver disorder, any kind of
colitis, Crohn=s disease, ulcerative colitis, irritable bowel syndrome, esophageal disorders, pancreatitis, gall
stones, stomach or intestinal bleeding and others?
12. HORMONE OR ENDOCRINE PROBLEMS: such as diabetes, thyroid disease, parathyroid or adrenal
problems and others?
13. URINARY TRACT PROBLEMS: such as kidney stones, pyelonephritis (kidney infection), nephrosis, single
functioning kidney, polycystic kidney disease, repeated bladder infections and others?
14. HERNIA: such as inguinal, umbilical, ventral, femoral, hiatal or incisional hernias?
15. MUSCLE, BONE AND JOINT PROBLEMS: such as chronic back or neck pain, numbness fibromyalgia, back
or neck disk disease, osteomyelitis (bone infection), muscular dystrophy, arthritis, spinal curvature, carpal tunnel
syndrome loss of a finger or toe, and others?
16. BLOOD SYSTEM PROBLEMS: such as anemia, hemophilia or bleeding disorder, white blood cell
abnormality and others?
(Continued on next page)
Page 3 F-1(LE) Rev. 6/11
Males Only:
17. Prostate problems such as enlargement or prostatitis?
18. Genital problems such as epididymitis or testicular injury?
Females Only:
19. Currently pregnant?
20. History of endometriosis, pelvic inflammatory disease, abnormal Pap smear, PMS or other problem with your
menstrual cycle?
Immunizations
21. Have you ever had a positive TB test?
22. Have you received Hepatitis B vaccinations?
23. When did you receive your last tetanus (lockjaw) immunization? __________________________________
Occupational History
Have you ever been exposed to any of the following, whether at home, work, military or any other setting? [check all that
apply]
24. Repetitive Loud Noises (Including guns, jet engines, loud machinery)?
25. Chemical exposure to skin or lungs?
26. Dusty conditions (sandblasting, grinding, mining or drilling of rock, coal, silica, asbestos)?
Check all YES answers:
27. Have you ever sustained an injury while at work that necessitated extended care by a health care provider?
28. Have you ever had a motor vehicle accident or other injury event causing back or neck pain?
29. Are you limited or unable to perform any physical activity because of muscle or joint discomfort?
30. Do you have any missing limbs or non-functional joints?
31. Do you have numbness, weakness, or pain in your upper extremities (including your hands)?
32. Have you ever been advised by a physician to avoid sitting or standing over a certain time?
33. Have you ever worked in law enforcement?
33a.If yes, have you ever missed more than three consecutive days of work for any medical or psychological
problem?
34. Have you ever served in any of the armed forces?
34a.If yes, have you ever missed more than three consecutive days or service for any medical or psychological
problem?
35. Do you have any medical condition that would prevent you from working extended shift periods, rotating shifts,
or night shifts?
36. Do you have difficulty sitting for any extended period of time?
37. Have you ever been advised by a physician to avoid lifting above a certain weight limit?
38. Do you have any difficulty in properly holding, aiming or firing a handgun, rifle or shotgun?
39. Do you have any difficulty driving at high speeds in a motorized vehicle?
40. Have you ever had an automobile accident while driving over sixty (60) miles per hour?
41. Have you ever had any automobile accidents as a result of losing control of your vehicle?
42. Do you have any difficulty driving for three (3) consecutive hours without stopping?
43. Do you have any difficulty running for five (5) consecutive minutes without stopping?
44. Have you ever passed out, temporarily lost control of any part of your body, or had blackout spells (episodes you
do not remember)?
(Continued on reverse side)
Page 4 F-1(LE) Rev. 6/11
Explanation of any “Yes” answers: (Identify by number)
Additional pages may be attached and must include your name, the last four digits of your social security number, and must
be signed and dated.
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Penalty:
Any falsification, withholding or failure to answer all questions completely and accurately may disqualify you from receiving
or retaining employment or certification as a criminal justice officer. Falsification regarding pre-existing conditions may
disqualify you from receiving benefits from your employer.
Certification:
I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and
answers to questions, and that all statements and answers are true and correct to the best of my knowledge and belief.
______________________________________________ _______________________________________
Signature of Applicant (Use Ink) Date Signed
Qualified Medical Professional Review:
______________________________________________
_______________________________________
Signature of Qualified Medical Professional Date Reviewed
(Use Ink)
Name, Title and Address of qualified medical professional completing review – Please Type.
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