RF 1231

NO. 1 MEDICAL REPORT

PERSONAL STATEMENT OF HEALTH
NOTE: This document is a Statutory Declaration. Questions not correctly or
fully answered, or the withholding of relevant information, may lead to
disqualification or instant dismissal and to prosecution for making a false
declaration under the Oaths Act 1936.

1.

Name: Date of Birth: ..

Address:
Present Occupation: .
Past Occupation (s): .....
Sporting Activities: ..

2.

Do you smoke tobacco? If so, in what form

and in what quantity per week?
YES / NO

Do you take alcohol? If so, in what form

and in what quantity per week?

YES / NO

Have you in the past or are you currently

using recreational drugs? or, non-prescribed medications.
If yes, name.
YES / NO

Do you take any prescribed medication?

Name, and give reasons for taking them.

YES / NO

Have you been immunised against Tetanus,

Diphtheria, Whooping Cough, Polio, Hepatitis?
If so, state which and year of vaccination. YES / NO

Have you received or are you seeking

compensation for any injury or illness?

YES / NO

Have you attended or enrolled in any special

education support programs during school?
YES / NO

3.

Have you suffered from or had symptoms of any of the following (indicate dates of illness, injury,
operation, symptom). If space provided is insufficient please attach additional sheet with information.
(a) Asthma, pneumonia, pleurisy, persistent
cough or any other affection of throat or
lungs?
YES / NO
(b)

Breathing difficulties or shortness of

breath?

YES / NO

NO. 1 MEDICAL REPORT

Page 2 of 5

(c) Allergies, hay fever?

YES / NO

(d) Skin disease / allergies?

YES / NO

(e) Convulsions, fainting, concussion?

YES / NO

(f)

YES / NO

(g) Emotional disorder, eating disorder?

YES / NO

(h) Anxiety, depression, phobia?

YES / NO

Insomnia, mental illness, nervous

breakdown?

YES / NO

Recurrent indigestion, stomach illness?

YES / NO

YES / NO

Have you ever consulted a chiropractor? YES / NO

(i)
(j)

Learning difficulties during school?

(k) Arthritis, bone or muscular pains, or

rheumatic fever?
(l)

(m) Do you wear orthotics and/or require special footwear?

YES / NO

(n) Have you ever suffered any sporting

injury?

YES / NO

(o) Disease of the bladder, the genital

organs, or the kidney (including renal
colic stones etc.)?

YES / NO

(p) Heart disease / condition, raised blood

pressure or chest pain or raised blood
cholesterol?

YES / NO

(q) Deafness, ear discharge, dizziness, or

sinus trouble?

YES / NO

YES / NO

(s) Diabetes?

YES / NO

(t)

YES / NO

(u) Hernia or rupture?

YES / NO

(v) Operations?

YES / NO

(w) Have you ever consulted a psychiatrist,

psychologist, hypnotherapist or
naturopath?

YES / NO

(r)

4.

Disease / condition of lung, bowel or

kidney?

Cancer or tumour of any type?

Give details of any accidents or illnesses not referred to above. Include details of medical
examinations, advice and/or treatments and also any x-rays had:

NO. 1 MEDICAL REPORT

5.

Family History:

(If deceased, state so. Give age as at time of death).

Full Name in Block Letters

Age

List any Illness Experienced by Each

and, if deceased, the Cause of Death

Father:

.....

....

Mother:

....

....

Brothers: ....

....

....

....

....

....

....

....

....

...

....

....

....

...

....

...

Sisters:

6.

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Has any near relative suffered from diabetes?

(If yes give details)
YES / NO

7.

Has any near relative suffered from epilepsy?

(If yes give details)
YES / NO

8.

Has any near relative suffered from any form

of heart disease?
(If yes give details)
YES / NO

9.

Have you ever stayed or lived for an extended

period (greater than 3 months) in a
high Tuberculosis (TB) risk country?
YES / NO

Are you aware of past contact with a TB

case?

YES / NO

Have you ever been treated for TB?

YES / NO

Have you ever had a positive Mantoux

skin test?

YES / NO

Has any near relative suffered from TB?

YES / NO

NO. 1 MEDICAL REPORT

10.

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Has any near relative suffered from any form

of mental disease or nervous breakdown
etc? (If yes give details)
YES / NO

11.

Do you now, or have you at any time, worn

glasses or contact lenses?
(If yes give details)
YES / NO

12.

Name and address of your family doctor:

DECLARATION
I ................................................................................................................................ DO SOLEMNLY AND SINCERELY DECLARE that the
foregoing information is true and correct and that I am not aware of any other circumstances which
might affect my eligibility to join the South Australia Police. And I make this solemn declaration
conscientiously believing the same to be true, and by virtue of the provisions of the Oaths Act
1936.

Declared at .....
this . day of ..... 20..

Before me: .................................................

(Signature of Applicant)

...................................................................
(Signature of Witness Justice of the Peace)

Revised: 2/12/2004

NO. 1 MEDICAL REPORT

Page 5 of 5

South Australia Police

"Leading the way to a safer community"
BOX 1539 GPO, ADELAIDE SA 5001
TELEPHONE: 8207 5000
ABN: 93 799 021 552
Your Ref
Our Ref
Enquiries
Telephone

Medical Section
8204 2215

AUTHORITY FOR RELEASE OF MEDICAL RECORDS

I, ..
(Full Name)

of .
(Address)

Authorise any Medical Practitioner or any other person who has treated me or

whom I have consulted for any illness, injury or condition, whether physical or

mental, to release to South Australia Police any information concerning my

health in his or her knowledge or possession, including copies of any specialist

or other reports.

Signed: .
(Signature of Applicant)

Dated: .
(Todays Date)

RF1231 Revised :2/12/2004