NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

Addendum B
Preliminary Health Evaluation
Detainee Name: Arrest #:
Date/Time DOB: Sex:
Booking Officer:
Cell:
Check YES or NO for each response. Any comments or notes are to be recorded on the bottom
with the number reference.
Is the detainee conscious?
Does the detainee have obvious pain or bleeding or other symptoms suggesting the need
for emergency care?
Are there visible signs of trauma, bruises, lesions or non-ease of movement requiring
immediate medical care?
Is there obvious fever, swollen lymph nodes, jaundice or evidence of infection which
might spread?
Is the skin in good condition and free of vermin?
Does the detainee appear to be under the influence of alcohol?
Yes
No
Does the detainee appear to be under the influence of drugs?
Are there any signs of alcohol and/or drug withdrawal symptoms?
Does the detainee’s behavior suggest a risk of suicide?
Does the detainee’s behavior suggest a risk of assault to staff or other detainees?
Is the detainee carrying medication or does the detainee report being on any medication,
which should be continually administered or visible?
Comments:
Officer - Detainee Questionnaire
Are you taking any medication for: diabetes, heart disease, seizures, arthritis, asthma,
ulcers, high blood pressure, or any psychiatric disorder? (Circle all that apply).
Comments:
Yes
No
PD-07-183
Revised March 17, 2011