Police Medical Questionnaire
Please fill out the following medical questionnaire. Your responses will remain confidential.
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
Other
Height (in inches)
Weight (in lbs)
Do you have any pre-existing medical conditions? If yes, please provide details.
Are you currently taking any medications? If yes, please provide details.
Have you ever had any surgeries? If yes, please provide details.
Do you have any allergies? If yes, please provide details.
Do you have any disabilities? If yes, please provide details.
Have you ever been diagnosed with a psychological or psychiatric condition? If yes, please provide details.
Are you currently receiving treatment or medication for a psychological or psychiatric condition? If yes, please provide details.
Do you have any vision impairments? If yes, please provide details.
Do you have any hearing impairments? If yes, please provide details.
Do you have any other physical limitations or conditions that may affect your ability to perform the duties of a police officer? If yes, please provide details.
Have you ever been treated for substance abuse or addiction? If yes, please provide details.
Are you currently using any illegal drugs or substances? If yes, please provide details.
Are you currently on probation or parole? If yes, please provide details.
Are you currently pregnant?
Yes
No
Additional Comments or Information
Submit
Should be Empty: