Application For A License To Practice Podiatric Medicine (Page 14 of 24) in pdf

PLEASE READ THESE QUESTIONS CAREFULLY BEFORE YOU RESPOND.

If you respond ‘yes’ to any question, please attach a complete explanation to your application. Failure to disclose

past history may be grounds for disciplinary sanctions.

WHEN IN DOUBT, DISCLOSE AND EXPLAIN.

PART V

PERSONAL HISTORY

Please refer to Special Instructions on page 4. For the purposes of the questions in this section, the following phrases or

words are defined:

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

reasonable 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 Drug 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.



38.

Yes. . . . . . Has your ability to practice medicine in a competent and safe manner ever been

impaired or limited by any condition, behavior, impairment, or limitation of a physical,

mental, or emotional nature?



39.

Yes. . . . . . Are you currently experiencing any medical condition or disorder that impairs your

judgment or that otherwise affects your ability to practice medicine in a safe and

competent manner?



40.

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

unable to practice medicine for a period of sixty (60) days or more?



41.

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

ability to practice in a safe and competent manner?



42.

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

voyeurism, pedophilia, exhibitionism, or any other sexual behavior disorder?

(Please note that “sexual behavior disorder” does not include sexual preference.)



43.

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

inhalation, or any other method?



44.

Yes. . . . . . 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 in a safe and competent manner?

Continued on next page

Applicant Name:

Date:

08-4109 (Rev. 10/15/14)

Application

Page 8 of 9

Application For A License To Practice Podiatric Medicine Page 14

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