Form 08-4022 - Application For Resident Permit

PART VI

PERSONAL HISTORY

For the purposes of the questions in this section only, the

following words and phrases are defined:

“Ability to Practice Medicine” includes, but is not limited to, the cognitive capacity to make appropriate clinical

diagnoses and exercise reasoned medical judgments and to learn and keep abreast of medical developments; the ability

to communicate those judgments and medical information to patients and other health care providers with or without the

use of aids or devices, such as voice amplifiers; and the physical capability to perform medical tasks such as physical

examination and surgical procedures, with or without the use of aids of devices, such as corrective lenses or hearing aids.

“Medical Condition” includes physiological, mental, or psychological conditions or disorders, such as, but not limited to,

orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis,

cancer, heart disease, diabetes, mental retardation, emotional or mental illness, specific learning disabilities, HIV disease,

tuberculosis, drug addiction, and alcoholism.

“Chemical Substance(s)” any natural or synthetic chemical substance, alcohol, drugs, or medications, including those

chemical substances taken pursuant to a valid prescription for legitimate medical purpose and in accordance with the

direction(s) of the prescribing physician, as well as those used illegally.

“Controlled Substances” means any substance as defined in either Alaska Statute 11.71.900 or the Federal

Comprehensive Dug Abuse Prevention and Control Act of 1970, 21 U.S.C.A. Section 801 et seq. (Public Law 91-513) and

any subsequent amendment(s).

“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application;

rather, “currently” means recently enough so that the event, condition, behavior, impairment, limitation, etc., may have an

ongoing impact on the applicant’s ability to practice medicine in a competent manner.

“Illegal Drug Use” means the use of an illegally obtained controlled substance or dangerous drug; the term “illegal drug

use” also means the use of a legally obtained controlled substance or dangerous drug which is not taken in accordance

with the directions of the licensed physician who prescribed the controlled substance or dangerous drug.

Has your ability to practice medicine in a competent and safe manner ever been impaired or

limited by any condition, behavior, impairment, or limitation or a physical, mental, or emotional

Yes

nature?

Are you currently suffering from any medical condition or disorder that impairs your judgement

Yes

or that otherwise affects your ability to practice medicine in a safe and competent manner?

Since completing your postgraduate training, have you ever been physically or mentally unable

Yes

to practice medicine for a period of thirty days or more?

Are you currently the subject of any civil investigation or court process relating to your ability to

Yes

practice medicine in a safe and competent manner?

Have you ever been diagnosed with, been treated for, or do you currently have pedophilia,

exhibitionism, or voyeurism, or any other sexual behavior disorder? (“Sexual behavior

Yes

disorder” does not include homosexuality, bisexuality, or any gender identity disorder resulting

from physical impairment.)

Are you currently engaged in the illegal use of any illegal drug, whether by ingestion,

Yes

inhalation, injection, or any other method?

Have you used or are you currently using any chemical substance(s), legal or illegal, that in

any way impaired or limited, or is currently impairing or limiting, your ability to practice medicine

Yes

in a safe and competent manner?

08-4022 (Rev 09/2000)

Page 3 of 4

Form 08-4022 - Application For Resident Permit - 2000 Page 3

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