Form F-1 (JJ) "Medical History Statement" - North Carolina

What Is Form F-1 (JJ)?

This is a legal form that was released by the North Carolina Department of Justice - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the North Carolina Department of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-1 (JJ) by clicking the link below or browse more documents and templates provided by the North Carolina Department of Justice.

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Download Form F-1 (JJ) "Medical History Statement" - North Carolina

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CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax (919) 779-8210
MEDICAL HISTORY STATEMENT
THIS INFORMATION IS FOR OFFICIAL USE ONLY AND WILL NOT
BE RELEASED TO UNAUTHORIZED PERSONS.
Form F-1 (JJ)
(Rev. 7.18)
INSTRUCTIONS:
To be completed by applicant for a certifiable position prior to the physical examination and presented to the
examining physician at the time of examination. All questions must be answered completely and accurately. The
original or a copy must be retained in personnel filed by the appointing agency.
Date:
Name:
Date of Birth:
Last
First
Middle
Address:
Street
City
State
Zip Code
Phone:
Last Four Digits of SSN:
CURRENT MEDICATIONS
Prescription Medications: (Include pain relievers, birth control pills, etc.)
Over the Counter Medications: (Include all cold allergy, headache, vitamins, etc.)
ALLERGIES
Drug Allergies: (Include your reaction to the mediation)
(Continued on reverse side)
Form F-1 (JJ), Rev. 7.18
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax (919) 779-8210
MEDICAL HISTORY STATEMENT
THIS INFORMATION IS FOR OFFICIAL USE ONLY AND WILL NOT
BE RELEASED TO UNAUTHORIZED PERSONS.
Form F-1 (JJ)
(Rev. 7.18)
INSTRUCTIONS:
To be completed by applicant for a certifiable position prior to the physical examination and presented to the
examining physician at the time of examination. All questions must be answered completely and accurately. The
original or a copy must be retained in personnel filed by the appointing agency.
Date:
Name:
Date of Birth:
Last
First
Middle
Address:
Street
City
State
Zip Code
Phone:
Last Four Digits of SSN:
CURRENT MEDICATIONS
Prescription Medications: (Include pain relievers, birth control pills, etc.)
Over the Counter Medications: (Include all cold allergy, headache, vitamins, etc.)
ALLERGIES
Drug Allergies: (Include your reaction to the mediation)
(Continued on reverse side)
Form F-1 (JJ), Rev. 7.18
All Other Allergies: food, insects, seasons, animals, materials, etc. : (Include reaction)
PAST MEDICAL HISTORY
List ALL hospitalizations and operations since childhood:
(Include type of surgery, date of surgery, any complications or other significant information)
Have you EVER, in your life, had any of the following types of medical problems? [check all that apply to you]
1. CANCER: any type of cancer including skin cancer, breast cancer, and leukemia?
2. MAJOR INFECTIOUS DISEASE: such as tuberculosis, hepatitis, HIV/AIDS, rheumatic fever and others?
3. NEUROLOGICAL PROBLEMS: such as seizure disorder, stroke, concussion, severe headache, skull fracture,
recurrent vertigo, balance problems, encephalitis, meningitis, tremors, multiple sclerosis, Huntington’s chorea,
peripheral neuropathy and others?
4. PSYCHOLOGICAL PROBLEMS: such as depression, manic episodes, psychotic episodes, post traumatic stress
disorder and others?
5. EYE PROBLEMS: such as eye injury, color blindness, poor night vision (night blindness), glaucoma, blindness in
one or both eyes, very poor vision when not corrected and others?
6. EAR PROBLEMS: such as ear injury, chronic ringing (tinnitus), chronic or long lasting ear infection, Meniere’s
disease, moderate to severe hearing loss in one or both ears and others?
7. NOSE PROBLEMS: such as nose injury, allergies, nasal bleeding, loss of sense of smell, chronic or long lasting
infections and others?
8. MOUTH OR THROAT PROBLEMS: such as injury, major dental work, any kind of speech defect, chronic or
long lasting infections, abnormality of nose, mouth or throat that would interfere with wearing a respirator and
others?
9. LUNG PROBLEMS: such as asthma, emphysema, chronic or recurrent bronchitis, pneumonia, tuberculosis or lung
abscess and others?
10. HEART AND CIRCULATION PROBLEMS: such as heart murmur, heart disease, heart attack, irregular rhythm,
valve abnormalities, varicose veins, phlebitis, peripheral vascular disease, Raynaud’s disease and others?
11. DIGESTIVE SYSTEM PROBLEMS: such as any kind of ulcer disease, hepatitis or liver disorder, any kind of
colitis, Crohn’s disease, ulcerative colitis, irritable bowel syndrome, esophageal disorders, pancreatitis, gall stones,
stomach or intestinal bleeding and others?
12. HORMONE OR ENDOCRINE PROBLEMS: such as diabetes, thyroid disease, parathyroid or adrenal problems
and others?
13. URINARY TRACT PROBLEMS: such as kidney stones, pyelonephritis (kidney infection), nephrosis, single
functioning kidney, polycystic kidney disease, repeated bladder infections and others?
14. HERNIA: such as inguinal, umbilical, ventral, femoral, hiatal or incisional hernias?
15. MUSCLE, BONE AND JOINT PROBLEMS: such as chronic back or neck pain, fibromyalgia, back or neck disk
disease, osteomyelitis (bone infection), muscular dystrophy, arthritis, spinal curvature, loss of a finger or toe, and
others?
16. BLOOD SYSTEM PROBLEMS: such as anemia, hemophilia or bleeding disorder, white blood cell abnormality
and others?
MALES ONLY:
17. Prostate problems such as enlargement or prostatitis?
18. Genital problems such as epididymitis or testicular injury?
(Continued on next page)
Form F-1 (JJ), Rev. 7.18
FEMALES ONLY:
19. Currently pregnant?
20. History of endometriosis, pelvic inflammatory disease, abnormal Pap smear, PMS or other problem with your
menstrual cycle?
IMMUNIZATIONS
21. Have you ever had a positive TB test?
22. Have you received Hepatitis B vaccinations?
23. When did you receive your last tetanus (lockjaw) immunization?
OCCUPATIONAL HISTORY
Have you ever been exposed to any of the following, whether at home, work, military or any other setting? [check all that
apply]
24. Repetitive Loud Noises (Including guns, jet engines, loud machinery)?
25. Chemical exposure to skin or lungs?
26. Dusty conditions (sandblasting, grinding, mining or drilling of rock, coal, silica, asbestos)?
Check all YES answers:
27. Have you ever sustained an injury while at work that necessitated extended care by a health care provider?
28. Have you ever had a motor vehicle accident causing back or neck pain?
29. Are you limited or unable to perform any physical activity because of muscle or joint discomfort?
30. Do you have any missing limbs or non-functional joints?
31. Have you ever been advised by a physician to avoid lifting above a certain weight limit?
32. Have you ever been advised by a physician to avoid sitting or standing over a certain time?
33. Have you ever worked in criminal justice?
33a. If yes, have you ever missed more than three consecutive days of work for any medical or psychological problem?
34. Have you ever served in any of the armed forces?
34a If yes, have you ever missed more than three consecutive days or service for any medical or psychological problem?
35. Have you ever passed out, temporarily lost control of any part of your body, or had blackout spells (episodes you do
not remember)?
EXPLANATION OF ANY YES ANSWERS: (Identify by number)
May use additional sheets of paper; write name, SS #, sign and date.
Form F-1 (JJ), Rev. 7.18
PENALTY:
Any falsification, withholding or failure to answer all questions completely and accurately may disqualify you from receiving
or retaining employment or certification as a Juvenile Justice Officer or Chief/Juvenile Court Counselor.
CERTIFICATION:
I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and
answers to questions, and that all statements and answers are true and correct to the best of my knowledge and belief.
Signature of Applicant (Ink)
Date Signed
PHYSICIAN REVIEW:
Signature of Physician/Physician’s Assistant/Nurse Practitioner (Ink)
Date Reviewed
Printed Name and Address of Physician Physician’s Assistant/Nurse Practitioner Completing Review
Form F-1 (JJ), Rev. 7.18