Commission on
Peace Officer Standards and Training (POST)
State of California Department of Justice
MEDICAL HISTORY STATEMENT Peace Officer
860 Stillwater Road, Suite 100
POST 2-252 (Rev 02/2013)
West Sacramento, CA 95605-1630
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting, or requiring, genetic information of an
individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family
member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual
or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Instructions:
Fill out the questionnaire completely and accurately. Keep in mind that all statements are subject to verification; deliberate inaccuracies or incomplete statements may
bar or remove you from employment. A “yes” answer does not necessarily mean that you will be disqualified.
This form must be completed and presented when reporting for your medical examination.
This medical history statement is confidential. If hired, the information you provide will be part of your medical record, separate from your personnel file.
Type or legibly print (in ink), or complete this form online at www.post.ca.gov/forms.aspx .
SECTION 1. CANDIDATE IDENTIFICATION
1. CANDIDATE’S NAME (Last, First, Middle)
4. ADDRESS W HERE YOU CAN BE CONTACTED (Street / P.O. Box)
7. PHONE NUMBERS W HERE YOU CAN BE REACHED
Day: ( ) - Evening: ( ) -
5. CITY
8. EMAIL
2. SOCIAL SECURITY NUMBER
Last 4 digits:
3. BIRTHDATE (MM/DD/YYYY)
6. STATE / ZIP
SECTION 2: JOB HISTORY AND PHYSICAL ACTIVITY
9. List current and all previous jobs held in the last 5 years, including military service.
JOB TITLE
A)
PRIMARY DUTIES EMPLOYER APPROXIMATE DATES
From:
To:
B)
From:
To:
C)
From:
To:
D)
From:
To:
E)
From:
To:
F)
From:
To:
G)
From:
To:
H)
From:
To:
I)
From:
To:
10. Describe your typical physical activity, including that at work. Indicate how often and how long you’ve been doing it.
A)
EXERCISE / ACTIVITY HRS PER WK HOW LONG?
yrs mos
B)
yrs mos
C)
yrs mos
Page 1 of 6
CLEAR PAGE 1
PRINT FORM
MEDICAL HISTORY STATEMENT Peace Officer
POST 2-252 (Rev 02/2013)
SECTION 3: MEDICAL HISTORY
Y N ?
Answer each of the following questions.
11.
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?
15.
Have you ever been terminated or resigned from employment, or had to change job positions due to a physical, psychological, or medically-
related reason?
16.
Are you currently under a health care provider’s care for any medical condition?
17.
Has your driver’s license ever been suspended or revoked due to medical reasons?
18.
Do you have any physical limitations?
19.
Do you need any reasonable accommodation to assist you in performing required job tasks?
20.
Have you ever been absent from work due to job stress?
21.
Have you missed more than five days from work in the past 12 months due to medically-related reasons?
22.
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?
28.
Do you ever wake up short of breath?
29.
Have you ever had any breathing problems using a gas mask? (Check “No” if you have never used a gas mask.)
30.
Do you currently smoke cigarettes? IF YES: How many packs per day? ____ For how long (in years)? ____
31.
Are you an ex-smoker? IF YES: How many years did you smoke? ____ Packs per day? ____ Approx date quit: _____________ (MM/YYYY)
32.
Have you used chewing tobacco or smoked cigars/pipes in the last 15 years?
33.
Have you ever had a p ositive drug or alcohol test?
34.
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?
40.
I am: Right-handed Left-handed
41.
Have you ever been hospitalized overnight (except for pregnancy)?
42.
Have you had any surgical operations?
43.
Have you sustained any disabling illnesses or medical conditions within the past 5 years?
44.
Have you been exposed to loud noise today? IF YES: Were you wearing hearing protection? Yes No
Page 2 of 6
CLEAR PAGE 2
MEDICAL HISTORY STATEMENT Peace Officer
POST 2-252 (Rev 02/2013)
SECTION 3: MEDICAL HISTORY
Y N ?
Answer each of the following questions.
45.
Do you occasionally use, or are you currently taking, any prescription or over-the-counter medications?
46. Have you taken any medication within the past 12 months for any reason?
47. Are you now receiving or have you ever received Workers Compensation?
48. Have you been rejected for, or discharged from the military because of, physical, mental, or other medically-related reasons?
49.
If you served in the military and were discharged, did you ever apply to the Veteran’s Administration (VA) for service-connected disability for
medical inj uries?
If YES, what percent disability classification do/did you have? _______%
For what kind of medical injury was the award granted? Provide details:
50. Briefly explain any items you marked “yes” or?.” In addition, describe anything else which you feel may be important in evaluating your medical
suitability for the position, including any condition(s) not specifically referred to in the preceding questions.
ITEM # EXPLANATION USE ADDITIONAL SHEETS IF NECESSARY
Page 3 of 6
CLEAR PAGE 3
MEDICAL HISTORY STATEMENT Peace Officer
POST 2-252 (Rev 02/2013)
SECTION 4: MEDICAL CONDITIONS Indicate if you have, or ever had, any of the following conditions. If you’re unsure, mark ?”
Indicate if you have, or ever had, any of the following conditions. If you’re unsure, mark “?
Y N ? Y N ? Y N ?
51. EYE, EAR, NOSE, THROAT
A) Eye surgery H) Glaucoma O) Ringing or buzzing in ears
B) Refractive surgery (e.g., Lasik, PRK) I) Blurred or double vision P) Hearing trouble
C) Orthokeratology / Retainer lenses J) Abnormal color vision test Q) Ear surgery
D) Vision therapy K) Sinus trouble R) Earache
E) Vision impairment L) Loss of smell S) Abnormal hearing test
F) Need to wear corrective lenses M) Allergy / Hay fever
G) Cataracts N) Ruptured ear drum
52. RESPIRATORY
A) Asthma (age at last episode: ______) D) Positive TB skin test G) Chest tightness
B) Shortness of breath E) Coughed up blood H) Wheezing
C) Chronic or frequent cough F) Pneumothorax (collapsed lung) I) Blood clot in lung
53. GASTROINTESTINAL
A) Ulcer / Stomach trouble F) Gall bladder trouble K) Abnormal liver test / Liver disease
B) Vomited blood G) Hepatitis L) Hernia
C) Persistent diarrhea H) Mucous in stool M) Irritable Bowel Syndrome
D) Colitis I) Black/bloody bowel movement N) Crohn’s disease
E) Recurrent hemorrhoids J) Pancreatitis
54. GENITOURINARY
A)
Kidney disease or stone
D)
Blood in urine
G)
Menstrual discomfort that kept you
from work
B)
Bladder trouble
E)
Prostatitis
H)
Currently pregnant
C)
Difficulty urinating
F)
Irregular vaginal bleeding
55. CARDIOV ASCUL AR
A)
Heart attack
E)
Enlarged heart
I)
Rheumatic fever
B)
Heart murmur
F)
Palpitation (irregular heartbeat)
J)
Swelling of foot or leg
C)
Heart failure
G)
High blood pressure
K)
Painful varicose veins
D)
Heart valve abnormality
H)
Pain or discomfort in chest
56. MUSCULOSKELETAL
A)
Fractured/broken bone
C)
Neck trouble/pain
E)
Arthroscopy
B)
Back trouble/pain
D)
Leg/shin pain
F)
Arthritis / Rheumatism
57. JOINT INJURY / SURGERY / DISLOCATION / PAIN / SWELLING
A)
Shoulder
D)
Fingers/toes
G)
Ankle/foot
B)
Elbow
E)
Hip
H)
Other joint pain or swelling
C)
W rist
F)
Knee
Page 4 of 6
CLEAR PAGE 4
MEDICAL HISTORY STATEMENT Peace Officer
POST 2-252 (Rev 02/2013)
SECTION 4: MEDICAL CONDITIONS continued
Indicate if you have, or ever had, any of the following conditions. If you’re unsure, mark “?
Y N ? Y N ? Y N ?
58. NEUROLOGICAL
A)
Epilepsy
F)
Head injury
K)
Skull defect
B)
Convulsion / Seizure
G)
Loss of consciousness
L)
Tremors
C)
Fainting spells / Blackouts
H)
Frequent/recurrent headaches
M)
Meningitis / Encephalitis
D)
Recurrent dizziness
I)
Migraine/sinus headaches
N)
Numbness of extremities
E)
Carpal Tunnel Syndrome
J)
Multiple Sclerosis
O)
Other
59. MISCELL ANEOUS
A)
Diabetes
I)
Cancer / Leukemia
Q)
Recurrent fever in the last year
B)
Low blood sugar
J)
Wool allergy
R)
Eczema
C)
Thyroid trouble
K)
Non-healing sores
S)
Claustrophobia
D)
Bleeding tendencies
L)
Chronic fatigue
T)
Sleep apnea
E)
Anemia
M)
Night sweats
U)
Snoring
F)
Enlarged glands
N)
Undesired weight loss or gain
V)
Sleep problems/disorders
G)
Cyst / Tumor
O)
Heat stress
W)
Any other problem or illness not listed
that may affect job performance
H)
Skin problems / Rashes
P)
Multiple chemical sensitivity
60. Explain any medical conditions you marked “yes” or “?.” Reference the corresponding item number and letter in your response (52B, 57F, etc.).
ITEM # EXPLANATION – USE ADDITIONAL SHEETS IF NECESSARY
Page 5 of 6
CLEAR PAGE 5
MEDICAL HISTORY STATEMENT Peace Officer
POST 2-252 (Rev 02/2013)
SECTION 5: CANDIDATE CONSENT
I hereby authorize the performance of a complete medical examination, x-rays, blood testing, and urine testing. I am aware that laboratory testing may be used to
detect illegal substances and therapeutic medications, and to verify my answers to the questions contained in this medical questionnaire. I also authorize the medical
examiner to obtain current or past medical records and to discuss my medical status and history with my treating physician or other medical consultants
as necessary. I declare that my answers are true to the best of my knowledge and belief. I am aware that any willful inaccuracy may be regarded as cause for
disqualification for employment.
SIGNATURE IN FULL DATE
SECTION 6: EXAMINING PHYSICIAN’S COMMENTS / NOTES
ITEM # COMMENTS / NOTES
Page 6 of 6
CLEAR PAGE 6
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome