MEDICAL HISTORY STATEMENT – Peace Officer
POST 2-252 (Rev 02/2013)
SECTION 3: MEDICAL HISTORY
Y N ?
Answer each of the following questions.
Have you ever worked as a peace officer before?
12. Have you ever failed to complete a peace officer academy training program?
13. Have you ever failed a p re-placement medical or psychological examination?
14. Have you ever been refused employment or been unable to hold a job because of any physical, psychological, or other medically-related reason?
Have you ever been terminated or resigned from employment, or had to change job positions due to a physical, psychological, or medically-
Are you currently under a health care provider’s care for any medical condition?
Has your driver’s license ever been suspended or revoked due to medical reasons?
Do you have any physical limitations?
Do you need any reasonable accommodation to assist you in performing required job tasks?
Have you ever been absent from work due to job stress?
Have you missed more than five days from work in the past 12 months due to medically-related reasons?
Have you ever been absent from work because of back/neck pain or problems?
23. Have you ever seen a d octor for back/neck pain or problems?
24. Do you currently have a cold or cough, or have you had either in the past two weeks?
25. In the past year, have you had a change in the size and color of a mole or a sore that would not heal?
26. Have you ever coughed, or wheezed, or had chest discomfort during or after exercise?
27. Have you ever taken medication to prevent wheezing or shortness of breath during exercise?
Do you ever wake up short of breath?
Have you ever had any breathing problems using a gas mask? (Check “No” if you have never used a gas mask.)
Do you currently smoke cigarettes? IF YES: How many packs per day? ____ For how long (in years)? ____
Are you an ex-smoker? IF YES: How many years did you smoke? ____ Packs per day? ____ Approx date quit: _____________ (MM/YYYY)
Have you used chewing tobacco or smoked cigars/pipes in the last 15 years?
Have you ever had a p ositive drug or alcohol test?
Are you now or have you ever been enrolled in a drug or alcohol rehabilitation program?
35. Per week, I drink: ____ bottles/cans of beer ____ glasses of wine ____ glasses of hard liquor
36. Has anyone ever been concerned about your drinking or suggested that you cut down?
37. Have you ever been convicted of driving under the influence (DUI)?
38. Have you ever felt bad about your drinking?
39. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
I am: Right-handed Left-handed
Have you ever been hospitalized overnight (except for pregnancy)?
Have you had any surgical operations?
Have you sustained any disabling illnesses or medical conditions within the past 5 years?
Have you been exposed to loud noise today? IF YES: Were you wearing hearing protection? Yes No
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