Supplemental Medical History Form
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2SUPPLEMENTAL MEDICAL HISTORY FORM
APPLICANTS: Complete all portions of this form. Failure to answer any questions or disclose a known medical
condition or failure to place signature where indicated may result in disqualification from employment
consideration. Please print or type. Each “yes” answer to a medical history question requires that you provide a brief
explanation in the comment section. This examination is being conducted for employment purposes only; it does not
substitute for a periodic health examination conducted by your private provider.
ATTENTION VETERANS/SERVICE MEMBERS: Even though some versions of the Questionnaire for National Security
Positions (SF-86) may not require you to disclose some types of mental health counseling, all mental health counseling
must be disclosed on this Medical Examination and History Report form in order to determine if you meet the
minimum medical qualifications for the position.
I have read and understand these instructions. APPLICANT SIGNATURE: _____________________________________
APPLICANT’S NAME (Last, First, Middle Initial):
SEX:
DATE OF BIRTH: (mm/dd/yy)
SOCIAL SECURITY NUMBER (or APPLICANT ID):
Male ☐ Female ☐
CHECK THE OCCUPATION FOR WHICH YOU ARE BEING CONSIDERED:
□ Border Patrol Agent
☐ Marine Interdiction Agent
□ Customs and Border Protection Officer
☐ Other:
MEDICAL HISTORY
Explain all “yes” responses.
Have you experienced any of the following?
Check one.
☐ Yes ☐ No
1 Diabetes
If yes, circle treatment: diet pills insulin
☐ Yes ☐ No
2 Blood disorder
☐ Yes ☐ No
3 Anemia
☐ Yes ☐ No
4 Phlebitis or blood clots
☐ Yes ☐ No
5 Lack of coordination, dizziness or balance issues
☐ Yes ☐ No
6 Tremors/shakiness
☐ Yes ☐ No
7 Loss of sensation
☐ Yes ☐ No
8 Crohn’s Disease, Colitis, or Irritable Bowel
Syndrome
☐ Yes ☐ No
9 Sleep disorders
☐ Yes ☐ No
10 Sleep apnea/sleep study
☐ Yes ☐ No
11 Organ transplant (e.g. kidney, etc.)
☐ Yes ☐ No
12 Heat stroke/heat exhaustion
☐ Yes ☐ No
13 Heart surgery
☐ Yes ☐ No
14 Stroke
☐ Yes ☐ No
15 Asthma (after age 12)
☐ Yes ☐ No
16 Corneal Refractive Therapy (CRT lenses)/
orthokeratology
☐ Yes ☐ No
17 Mental health treatment or counseling
☐ Yes ☐ No
18 Diagnosed with depression, anxiety, or PTSD
☐ Yes ☐ No
19 ADD/ADHD
☐ Yes ☐ No
20 Have you ever applied for, or received, pension
or compensation for a disability? (VA, Social
Security, Workers’ Compensation, etc.)
1/29/2016
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