Form T-1 - Kentucky Law Enforcement Council Medical Release
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1Office Use Only
Form T-1
Kentucky Law Enforcement Council
M
R
EDICAL
ELEASE
Mail:
Kentucky Law Enforcement Council
INSTRUCTIONS: This form must be completed by the
Funderburk Building
applicant prior to participating in the physical agility. Please
521 Lancaster Ave.
Richmond, KY 40475-3102
have applicant bring form to the test site at the time of testing
Phone:
859-622-6218
Fax: 859-622-5943
along with picture identification.
Name of Applicant __________________________________________________
Date of Birth _________________
SSN _______________________________
YES
NO
1.
Has a doctor ever said you have heart trouble?
2.
Do you frequently suffer from chest pains?
3.
Do you often feel faint or have severe spells of dizziness?
4.
Are you over age fifty (50) and not accustomed to vigorous exercise?
5.
Has a doctor ever said you have an abnormal electrocardiogram (ECG)?
Do you have diabetes?
6.
7.
Do you have a close family relative (mother, father, sister, brother) who
has heart disease before age 50?
8.
Has a doctor ever said you have high cholesterol or blood fats?
9.
Has a doctor ever said you have high blood pressure?
10.
If you are 35 or older: Do you smoke?
11.
Has a doctor ever told you that you have a muscle, skeletal, or joint
problem which would stop you from doing any type of exercise?
12.
Optional: What is your reading for the following:
Blood Pressure:
SBP_____________
DBP_____________
Optional: Blood lipids:
13.
Total Cholesterol________________
Total to HDL Ratio ______________
If any one item between numbers 1-11 is checked “YES,” the Physician’s Medical
Release Form (T-1a) must be completed.
These forms must be received in the
KLEC office on or before the scheduled date for Phase I Testing.
I hereby verify that the above information is true and accurate.
Signed this _________ day of________________, 20______.
______________________________________________________
Signature of Applicant
__________________________________________________________________________
Printed Name of Applicant
Revised July 2010
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