ESBD_510338_1777061277225_SOL_EXH_F.9_RC-13-Medical Personal History Form Sample.pdf

RC-13 (Revised 9/13) Page 1

CONFIDENTIAL

PERSONAL HISTORY STATEMENT

MEDICAL-RELATED INQUIRIES

Name:_________________________________________ LAST FOUR SSN:_______________________

Date:_________________________________

The inquiries on the following pages should only be asked of applicants/candidates who have received a conditional job offer.

This form is not given out to applicants/candidates in the selection process who have not been made a conditional job offer of employment (including a promotional offer).

Medical-related inquiries should only be asked of applicants/candidates who have been made a conditional job offer and should only be made where the information is necessary to determine suitability for the job in question. Any rejection of an applicant/candidate based on the information contained as a result of these inquiries must be job-related and consistent with business necessity.

The Americans with Disabilities Act (ADA) requires that the information obtained in the course of a conditional job offer, medical examination or inquiry is to be treated as a confidential medical record and may be used only in a manner consistent with the ADA. Therefore, if the following pages are completed, after use during the selection process, they must be returned to the Human Resources Bureau to be filed in separate medical files.

Applicants/candidates, who are to fill out this form, MUST also complete a Medical Release Form HR-99c.

It is the applicant’s responsibility to notify the Recruiting Department about any medical procedures, or injuries sustained, after the “Conditional Job Offer” or offer for employment has been given. Failure to do so will result in the applicant’s “Conditional Job Offer” to be rescinded and the applicant will have to re-apply to the agency.

Due to the high degree of intensity and physicality in the Physical Fitness and Tactics training protocols failure to report such surgeries, or injuries, can lead to serious acute (short term) and chronic (long term) injuries while in Recruit training. The applicant must be physically fit and free of any injury or medical condition that could result in complications with this type of training.

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TEXAS DEPARTMENT OF PUBLIC SAFETY

(FOR POSITION OF COMMISSIONED PEACE OFFICER)

MEDICAL HISTORY

Note: Upon completion of your medical examination and evaluation of your personal medical history, the attending physician, based on their professional opinion, may request that a further medical evaluation by a specialist be required before rendering a recommendation for employment as a Trooper-Trainee.

1. Name:___________________________________________________________

2. Mailing Address:___________________________________________________

3. Date of Birth:______________________________________________________

4. Gender: Female Male

5. Marital Status: Never Married Married Widowed

Divorced Separated

6. Current Occupation:________________________________________________

7. To the best of your knowledge have you ever had or do you now have symptoms or a diagnosis of any of the following: (Please check all that apply. Also give details on all checked boxes, including: name of condition, date of condition, body part(s) affected, cause, length of impairment/injury, and any permanent disability.)

a) Varicose Veins Yes No

Details ……………………………………………………………………………………

b) Anemia Yes No

Details ……………………………………………………………………………………

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c) Thyroid Disorder Yes No

Details …………………………………………………………………………………….

d) Bleeding Tendency Yes No

Details …………………………………………………………………………………….

e) Dizziness of fainting Yes No

Details …………………………………………………………………………………….

f) Epilepsy Yes No

Details …………………………………………………………………………………….

g) History of headaches Yes No

Details …………………………………………………………………………………….

h) Heat stroke Yes No

Details …………………………………………………………………………………….

i) Hernia Yes No

Details ……………………………………………………………………………………

j) Hemorrhoids Yes No

Details ……………………………………………………………………………………

k) Prostrate problem Yes No

Details ……………………………………………………………………………………

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l) Severe menstrual disturbances Yes No

Details ……………………………………………………………………………………

m) Currently pregnant Yes No

Details ……………………………………………………………………………………

n) Severe allergies Yes No

Details ……………………………………………………………………………………

o) Asthma Yes No

Details ……………………………………………………………………………………

p) Other respiratory problems Yes No

Details ……………………………………………………………………………………

q) Food allergies Yes No

Details ……………………………………………………………………………………

r) Medication allergies Yes No

Details …………………………………………………………………………………….

s) Incontinence Yes No

Details …………………………………………………………………………………….

t) Other urinary tract problems Yes No

Details …………………………………………………………………………………….

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u) Irregular or loose bowel movements Yes No

Details …………………………………………………………………………………….

v) Ulcers or other digestive disorders Yes No

Details …………………………………………………………………………………….

w) Insomnia or other sleep disorders Yes No

Details …………………………………………………………………………………….

x) Impairment of sight or eye injury Yes No

Details …………………………………………………………………………………….

y) Impairment of hearing or ear injury Yes No

Details …………………………………………………………………………………….

z) Chronic infections Yes No

Details …………………………………………………………………………………….

aa) Current or recent infections Yes No

Details …………………………………………………………………………………….

bb) Any staph infections Yes No

Details …………………………………………………………………………………….

cc) Tuberculosis Yes No

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dd) Meningitis Yes No

Details …………………………………………………………………………………….

ee) Hepatitis Yes No

Details …………………………………………………………………………………….

ff) Syphilis Yes No

Details …………………………………………………………………………………….

gg) Herpes Yes No

Details …………………………………………………………………………………….

hh) Other STD Yes No

Details …………………………………………………………………………………….

ii) Other recent or current contagious disease Yes No

Details …………………………………………………………………………………….

jj) Cancer Yes No

Details …………………………………………………………………………………….

kk) Other serious illness Yes No

Details …………………………………………………………………………………….

ll) Other serious injury Yes No

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mm) Cardio History:

Details ……………………………………………………………………………………..

A. Family History:

I. Did your father or male first-degree relative (i.e., brother or son) have a myocardial infarction (heart attack), coronary revascularization (bypass, stent, etc.), or sudden death before 55 years of age?

Yes No

II. Did your mother or female first-degree relative (i.e., sister or daughter) have a myocardial infarction (heart attack), coronary revascularization (bypass, stent, etc.), or sudden death before 65 years of age? Yes No

B. Signs or symptoms suggestive of cardiovascular and pulmonary disease:

I. Have you experienced any of the following symptoms at rest or during physical activity:

a. Pain, discomfort in the chest, neck, jaw, arms or other areas?

Yes No

b. Shortness of breath or wheezing at rest or with mild exertion?

Yes No

c. Dizziness, fainting or blackouts?

Yes No

d. Difficulty breathing except in an upright position or episodes of respiratory distress that awaken you from sleep?

Yes No

e. Ankle edema (swelling of feet, ankles or lower legs unrelated to injury)? Yes No

f. Heart palpitations (irregular or racing heartbeat on more than one occasion)? Yes No

g. Intermittent claudication (leg pain that causes you to stop walking)?

Yes No

h. Known heart murmur?

Yes No

i. Unusual fatigue or shortness of breath with usual activities?

Yes No

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C. Have you ever been told by a health professional that you have had any of the following:

I. Abnormal resting or exercise (treadmill) electrocardiogram (ECG, EKG)? Yes No

II. Heart enlargement? Yes No

III. Heart attack? Yes No

IV. Stroke? Yes No

V. High or low blood pressure? Yes No

VI. Circulatory problems? Yes No

VII. High cholesterol? Yes No

VIII. Abnormal blood sugar? Yes No

8. Do you smoke or use other tobacco products? If yes, list frequency of use and type of tobacco used. Yes No

9. If you smoked or used tobacco products in the past, when did you quit?

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10. Knee:

A. Have you ever suffered any knee injury, which lasted more than 1 week? If yes, please explain. Give dates. Yes No

B. Have you had surgery on your knee(s)? If yes, please explain.

Give dates. Yes No

C. Has your knee(s) ever been swollen? If yes, please explain. Give dates. Yes No

D. Have you ever had to wear a “brace” for your knee(s)? If yes, please explain. Give dates. Yes No

E. Have you ever been restricted from any activities or sports because of your knee(s)? If yes, please explain. Give dates.

Yes No

F. Does your knee(s) make crunching sounds or cause pain when you are doing stairs, hills, etc.? If yes, please explain. Give dates.

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11. Shoulder:

A. Have you ever had your shoulder “pop out” of socket or be dislocated? If yes, please explain. Give dates.

Yes No

B. Does your shoulder make popping or crunching sounds? If yes, please explain. Give dates. Yes No

C. Have you ever had a rotator cuff tear or fracture to the shoulder or collar bone area? If yes, please explain. Give dates.

Yes No

12. Foot/Ankle:

A. Do you have flat feet? If yes, please explain. Give dates.

Yes No

B. Do your feet ever hurt when you walk or run for any distance? If yes, please explain. Give dates. Yes No

C. Do you wear special inserts in your shoes to perform athletic activities? If yes, please explain. Give dates.

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D. Have you ever broken your foot or heel? If yes, please explain.

Give dates. Yes No

E. Have you ever suffered from ankle sprains or other ankle injuries?

If yes, please explain. Give dates. Yes No

13. Pelvic Region:

A. Have you ever had a hip injury or hip pain (e.g. dislocation, fracture, replacement)? If yes, please explain. Give dates.

Yes No

B. Have you ever fractured your pelvis? If yes, please explain. Give dates. Yes No

14. Back/Neck:

A. Have you ever suffered any back/neck/spinal injury or pain? If yes, please explain. Give dates. Yes No

B. Have you ever had surgery on your back/neck/spine? If yes, please explain. Give dates. Yes No

C. Have you ever seen a doctor/chiropractor for the back/neck/spinal area? If yes, please explain. Give dates. Yes No

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15. General Orthopedic:

A. Do any of your joints bother you (tenderness/pain)? If yes, please explain. Give dates. Yes No

B. Have you ever been diagnosed with arthritis or rheumatism? If yes, please explain. Give dates. Yes No

C. Have you ever been diagnosed with carpal tunnel tendonitis? If yes, please explain. Give dates. Yes No

D. Do you presently take any over-the-counter or prescription anti-inflammatory medication on a regular basis? (e.g. Advil, Aleve, etc.)? If yes, please explain. Give dates. Yes No

E. Have you had any other fractured bones/torn muscles or ligaments that have not been listed? If yes, please explain. Give dates.

Yes No

F. Have you ever had orthopedic surgery of any kind? If yes, please explain. Give dates. Yes No

G. Do you have any metal or prosthetic devices implanted in you from any kind of surgery? If yes, please explain. Give dates.

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H. Have you ever had a pinched nerve? If yes, please explain. Give dates. Yes No

16. Do you consume caffeine drinks? If yes, list frequency of use.

Yes No

17. Are you taking any drugs or medications whether prescriptions or otherwise? Yes No

If yes, please describe:

1 2 3

Name of medication Type of medication Purpose Side Effects

4 5 6 Name of medication Type of medication Purpose Side Effects

18. Are you currently using or have ever used any of the following drugs illegally: Yes No

NAME STREET NAMES TIMES

TAKEN

YEAR

STIMULENTS

Benzedrine, Obetrol Ice, Speed, Crank

Desoxyn Upper, Snot, Glue

Cocaine Coke, Rock, Crack

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Snow

Other Amphetamines Dexies, Crystal, Black Beauties, Bennies

Other Methamphetamines

Meth, Glass, Chalk, Crystal Meth

ANALGESICS

Codeine Schoolboy

Roxanol “M” Morph

Heroin Horse, Smack, “H”, Speedball (w/cocaine)

Dilaudid Juice, Dillies

Demerol Demmies, Pain Killer

Dolophine Dollies, Meth

Talwin T’s

Darvon Pain Killer

Hycodan, Vicodin “

Percodan “

Percoset “

Oxycontin Oxy, Hillbilly Heroin

HALLUCINOGENS

Marijuana MJ, Grass, Pot, Smoke

LSD LSD

PCP Angel Dust, Hog

MDA Love Boat, Hug Drug

MDMA Adam, Ecstasy, X, E

DEPRESSANTS/SEDATIVE/HYPNOTIC

GHB G, Liquid Ecstasy

BARBITURATES

Luminal Downers, Goofballs

Seconal Seconds, Reds

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Nembutal Nembies

Fiorinal, Fioricet Phennies

Talbutals Tooies

Butisol Bute, Stoppers

Amytal Blue Devils, Yellow Jackets

Alurate Barbs, Rainbows

BENZODIAZEPINES

Rohypnol “Roofies”

Librium Downers, Nerve Pills, Candy

Clonopin “

Valium “

Dalmane “

Ativan “

Serax “

Xanax “

Tranxene Tranks

Quaalude Ludes

Steroids Roids, Stack, Juice

19. At anytime have you ever used any other illegal drug, not listed or used either prescription drugs and/or over the counter medications in excess of recommended usage and/or for purposes other than the intended use? If yes, please explain. Give dates. Yes No

20. At anytime have you ever used any abusable volatile chemicals for uses other than their intended use such as glue, spray paints, hair sprays, paint thinner, etc.? If yes, please explain. Give dates. Yes No

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21. Do you consume alcohol? Yes No

If yes: Light Moderate Heavy

TYPE OF ALCOHOL AMOUNT CONSUMED WEEKLY

Liquor ________________________________

Beer ________________________________

Wine ________________________________

Wine Coolers ________________________________

Other Adult Beverages ________________________________

22. Do you currently have a problem with alcohol use? If yes, are you currently receiving treatment? Yes No

23. List all public intoxications and/or alcohol related offenses that you have been charged with and the date of the offenses:

ARRESTING AGENCY DATE OF OFFENSE

24. Have you ever committed any alcohol/drug related offenses for which you were not arrested? If yes, please explain. Give dates. Yes No

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25. Do you have any workers’ compensation claims pending for injuries sustained against any former Employer or insurance company? If yes, name employer and type of injury? Yes No

26. Have you ever been hospitalized? If yes, please explain, including type of injury, date, length and reason of hospitalization: Yes No

27. Have you ever undergone an operation? If yes, what kind? Give dates.

Yes No

28. Have you ever had any RD – Radial Keratotomy (incision), PRK – Peripheral Refractive Keratotomy (laser) or other type of eye surgery? If yes, when and what type? Yes No

29. Have you been treated for or under the care of a physician/psychologist for depression, mental illness, and/or emotional problems in the last 5 years? If yes, please explain. Give dates. Yes No

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30. Do you suffer from any mental health condition that could impact your performance of the duties of the job which you are applying? If yes, please explain. Yes No

31. Have you been treated by a doctor (other than routine examinations) in the last year? If yes, please explain, including date and reason for treatment:

Yes No

32. Do you have any other medical condition not covered elsewhere that may bear on your ability to perform the duties of this job for which you are applying? If yes, please explain. Yes No

33. Have you had tetanus inoculation in the past ten years?

Yes No Don’t know

If you answered “no” or “don’t know”, it is highly recommended, but not required, that you receive a tetanus inoculation before beginning the Academy. Due to the nature of the profession, it is also recommended, but not required, that all DPS commissioned officers stay current on available vaccines against communicable diseases. Consult with your physician about the appropriateness for you of the various vaccines.

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34. Diabetes or abnormal blood sugar Yes No

Details

1. Diabetes:

A. What type of Diabetes do you have and when were you first diagnosed?

Type I Type II

B. If you have Type I (insulin dependent) Diabetes, how much insulin do you take each day?

C. Have you ever suffered from diabetic ketoacidosis (severe high blood sugar level)? If yes, please explain. Give dates. Include information about the severity of each case. (Did you experience dizziness or pass out? Need medical treatment or help of other person to recover? Etc.)

Yes No

D. Have you ever suffered from hypoglycemia (severe low blood sugar level)? If yes, please explain. Give dates. Include information about the severity of each case. (Did you experience dizziness or pass out? Need medical treatment or help of other person to recover? Etc.) Yes No

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E. Have you ever been involved in a sport or other activity that required extended strenuous physical exertion (longer than 30 minutes of intense aerobic activity

– in the heat of the day, cold temperatures, high humidity, etc.)? If yes, were you able to control your sugar/insulin levels to avoid ketoacidosis/hypoglycemia. If no, please explain. Yes No

F. If you were involved in an emergency situation that caused you to delay or miss a meal/be unable to eat or take medication, would this be a problem? If yes, please explain, including information on how long a delay would have to be before it became a problem. Yes No

35. Seizures of any type or intensity. If yes, complete questions below.

Yes No

Details

1. Seizures:

A. What type of seizures do you have, what is the underlying cause and when were you first diagnosed?

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B. Do you take medication to control your seizures? Yes No If no, how long have you been seizure free?

If yes, what kind, how much and how often do you take the medication?

C. Have you experienced a seizure in the last five years? If yes, please explain.

Give dates. Include information about the severity of each case. (Did you experience unconsciousness? Muscle spasms? Need medical treatment or help of other person to recover? Etc.) Yes No

36. Prior head, face, neck injuries. If yes, complete questions below.

Yes No

Details

1. Head, Neck and Face Injuries:

A. Did the injury result in any of the following symptoms or diagnosis (headache, dizziness, impaired vision, memory loss, numbness in body part, nose injury, shoulder “stinger” or burner”, nausea, vomiting, hearing problem, loss of consciousness, concussion)? If yes, please explain the symptoms, the longest duration of symptoms, how it affected your work, participating in sports or leisure activities of daily living. Yes No

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B. If you have experienced the above symptoms, answer the following questions:

Yes No

I. How many times did you experience these symptoms after any injury in the last few years?

II. How many times did you experience a concussion with these symptoms after an injury in the last few years?

III. List the longest duration you experiences the symptoms after an injury in the last few years:

IV. List the longest duration you were unable to work or participate in sports and leisure activities because of these symptoms after an injury in the last few years:

37. Please provide any additional medical information that was not covered in this questionnaire.

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I certify that the above answers are true and correct to the best of my knowledge. I agree that any false statements or omissions of any facts may be cause for rejection of my application for employment with Texas Department of Public Safety. Any such false statements or omissions discovered subsequent to my appointment may be cause for dismissal.

Signature Last Four SSN

Witness Date