NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

Addendum B
Officer – Detainee Questionnaire (Continued)
Check YES or NO for each response. Any comments or notes are to be recorded on the bottom
with the number reference.
Do you have a special diet prescribed by a physician?
Yes
No
Do you have a history of venereal disease, HIV, or abnormal discharge?
Have you recently been hospitalized or seen a medical or psychiatric doctor?
Are you allergic to any medication?
Have you fainted recently or had a recent head injury?
Do you have epilepsy, diabetes, hepatitis, or a history of tuberculosis?
Do you have any other medical needs?
Have you ever contemplated suicide?
Are you contemplating suicide now?
Comments:
Female Detainees
Check YES or NO for each response. Any comments or notes are to be recorded on the bottom
with the number reference.
Are you pregnant?
Yes
No
Are you on birth control?
Have you recently delivered a baby?
If yes, date delivered: _______________________
Do you have any other medical conditions that we should know about?
Comments:
Physician Name:
Address:
Phone
Number:
Detainee Signature:
Officer Signature:
PD-07-183
Revised March 17, 2011