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    Medical Examination Form For Police Applicants

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    Elite Mission Hospital
    This document appears to be a medical examination form for police applicants in Saskatchewan. It collects personal information about the applicant like name, address, and date of birth. It documents their health history through a series of yes/no questions about illnesses, injuries, surgeries, and other medical conditions. The physical examination section records vital signs and evaluates various body systems. Laboratory tests are also listed to be performed. At the end, the examining physician must determine if the applicant is physically fit for duty as a police officer.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Examination Form For Police Applicants

    Uploaded by

    Elite Mission Hospital
    155 views2 pages
    This document appears to be a medical examination form for police applicants in Saskatchewan. It collects personal information about the applicant like name, address, and date of birth. It documents their health history through a series of yes/no questions about illnesses, injuries, surgeries, and other medical conditions. The physical examination section records vital signs and evaluates various body systems. Laboratory tests are also listed to be performed. At the end, the examining physician must determine if the applicant is physically fit for duty as a police officer.

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    Medical Examination Form for Police Applicants

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    This document appears to be a medical examination form for police applicants in Saskatchewan. It collects personal information about the applicant like name, address, and date of birth. It documents their health history through a series of yes/no questions about illnesses, injuries, surgeries, and other medical conditions. The physical examination section records vital signs and evaluates various body systems. Laboratory tests are also listed to be performed. At the end, the examining physician must determine if the applicant is physically fit for duty as a police officer.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    155 views2 pages

    Medical Examination Form For Police Applicants

    Uploaded by

    Elite Mission Hospital
    This document appears to be a medical examination form for police applicants in Saskatchewan. It collects personal information about the applicant like name, address, and date of birth. It documents their health history through a series of yes/no questions about illnesses, injuries, surgeries, and other medical conditions. The physical examination section records vital signs and evaluates various body systems. Laboratory tests are also listed to be performed. At the end, the examining physician must determine if the applicant is physically fit for duty as a police officer.

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    Saskatchewan

    Police Medical Examination Form


    Commission
    for Police Applicants
    Police Department: ___________________________________________________________________________
    Examined by: _______________________________________ Date: _________________________________
    Address: ___________________________________________ Phone: ________________________________
    ____________________________________________________________________________________________
    Applicant:
    Surname: __________________________________________ Christian Names: _______________________
    Address: ________________________________________________ DOB: ________________ Sex: _______
    (Street)
    ____________________________________________________________________________________________
    (City or Town) (Province) (Postal Code)
    Name of Family Physician: __________________________________ Phone: ___________________________

    Health History
    Have you ever had or are you suffering from
    Yes No Yes No Yes No
    1. Illness or injuries 12. Lung disease or 23. Back injuries and/or
    since previous exam ❒ ❒ chronic cough ❒ ❒ back problems ❒ ❒
    2. Eye trouble ❒ ❒ 13. Shortness of breath ❒ ❒ 24. Broken bones ❒ ❒
    3. Ear trouble or deafness ❒ ❒ 14. Indigestion ❒ ❒ 25. Foot troubles ❒ ❒
    4. Nose or throat trouble ❒ ❒ 15. Jaundice ❒ ❒ 26. Rheumatism or
    16. Rupture ❒ ❒ joint trouble ❒ ❒
    5. Hay fever – Asthma –
    Sinusitis ❒ ❒ 17. Hemorrhoids ❒ ❒ 27. Bleeding disorders ❒ ❒
    6. Headaches ❒ ❒ 18. Kidney and/or 28. Nervous disorders ❒ ❒
    7. Head injuries ❒ ❒ bladder trouble ❒ ❒ 29. Used alcoholic beverages

    8. Fainting spells – 19. Veneral disease ❒ ❒ to excess ❒ ❒


    Convulsions ❒ ❒ 20. Varicose veins ❒ ❒ 30. Operations ❒ ❒
    9. Heart disease ❒ ❒ 21. Tropical diseases ❒ ❒ 31. Allergies ❒ ❒
    10. Rheumatic Fever ❒ ❒ 22. Skin disease ❒ ❒ 32. Drug allergies ❒ ❒
    11. Palpitations ❒ ❒ 33. On any medication ❒ ❒
    34. Other: __________________________________________________________________________________________________________

    Details of Positive Health History


    _____________________________________________________________________________________________
    _____________________________________________________________________________________________
    _____________________________________________________________________________________________
    Height Weight Physique
    _____________________________________________________________________________________________
    Complexion Skin disease(degree) Hair colour Eye colour
    _____________________________________________________________________________________________
    Chest measurements (male only)
    (a) Full inspiration In. (b) Forced expiration In.
    _____________________________________________________________________________________________
    Vision without aids Vision with aids
    R L R L
    Glasses Yes _____ If “Yes” are present Yes ____ Colour vision (City University or
    Required? No ______ ones satisfactory? No _____ Farnsworth D15 test)
    Physical Examination
    ____________________________________________________________________________________________
    Blood Pressure Pulse
    Systolic Diastolic Irregular ❒ Regular ❒

    Normal Abnormal
    1. Lymphatic System ❒ ❒
    2. Hearing (cv)
    R L ❒ ❒
    3. Ear (drums)
    R L ❒ ❒
    4. Head ❒ ❒
    5. Nose (passages) ❒ ❒
    6. Mouth (teeth) ❒ ❒
    7. Throat (tonsils) ❒ ❒
    8. Chest ❒ ❒
    9. Lungs ❒ ❒
    10. Heart ❒ ❒
    11. Spine ❒ ❒
    12. Abdomen ❒ ❒
    13.Hernia ❒ ❒
    14. Genito-urinary ❒ ❒
    15. Varicocele ❒ ❒
    16. Hemorrhoids ❒ ❒
    17. Extremities ¨ ¨
    15. (a) Hands ❒ ❒
    15. (b) Feet ❒ ❒
    15. (c) Varicose veins ❒ ❒
    18. Reflexes ❒ ❒

    Females Only
    Breast Examination — to determine presence of nodules or tumors.
    Gynaecological History — with pelvic examination including pap smear.

    Laboratory Examination

    Blood Wassermann Haemoglobin E.S.R. Blood group Rh.


    Urinalysis
    Albumen Sugar Microscopic
    Chest X-Ray (if necessary in physician’s opinion)
    Film No. Where taken
    Report:
    ECG — after age 39 years
    Other studies as deemed necessary
    Is applicant physically fit for employment as a Police Officer? Yes ❒ No ❒ Temporary Rejection ❒

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