Medical Consent And Release Forms -City Of Louisville Page 3
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3Medical Consent and Release Forms
Applicant Medical Release
Applicants must answer ALL questions to be eligible to complete Louisville Metro Department of Corrections
(LMDC) physical agility testing exercises. Any applicant who answers yes to the below listed conditions must
obtain a physician’s release before completing the physical agility test.
Name: _____________________________
SS#: ________________________
Date of Birth: _______________________
Yes
No
___
___
1. Has a doctor ever said that you have heart trouble?
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___
2. Do you frequently suffer from chest pain?
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3. Do you often feel faint or have spells of severe dizziness?
___
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4. Do you have any pulmonary disease or difficulty breathing?
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5. Are you over the age of 50 and not accustomed to vigorous exercise?
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6. Has a doctor ever said that you have an abnormal electrocardiogram (ECG)?
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7. Do you have diabetes?
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8. Do you have a close family relative (mother, father, sister, brother) who had
heart disease before the age of 50?
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9. Has a doctor ever said that you have high cholesterol or blood fats?
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10. Has a doctor ever said that you have high blood pressure?
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11. Has a doctor ever said that you have a muscle, skeletal or joint problem that would
prevent you from doing any type of exercise?
___
___
12. If you are 35 or older, do you smoke?
If you marked “yes” to any question, the attached Physician’s Medical Release form must be completed by a
physician duly licensed to practice in Indiana or the Commonwealth of Kentucky. The medical release must be
received by our office before you will be scheduled for the applicant physical agility test.
I hereby verify that the above information is true and accurate.
Signed this ______ day of ________________, 20 _____
__________________________________
_______________________________
Printed Name of Applicant
Signature of Applicant
Adopted from the Kentucky Law Enforcement Council Peace Officer Standards Medical Release (form T-1)
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