Medical Information

Medical Information

Often one's medical condition can mimic intoxication and may affect one's performance with the police. Please complete each question fully and completely. An omission can adversely affect the outcome of your case.
If you have sought medical treatment for any physical or psychological condition, please list them below in chronological order from oldest to most recent. Obtain a copy of these medical records for treatment in the past 10 years and provide me with a copy of those records.
Symptom 1:
Symptom 2:
Symptom 3:
Symptom 4:
Symptom 5:
Symptom 6:
Have you been hospitalized at any medical facility?
When was the last time you were examined by a medical care provider (physician, nurse, practitioner, chiropractor, etc.) other than for a scheduled checkup?
Are you currently under the care of a doctor?
Were you taking any medication or drugs at the time such as cold pills, aspirin, antihistamines, tranquilizers, weight control pills, etc.?
Were you warned by your doctor, pharmacists, or nurse, of any side effects of the medication?
Do you have any physical disability which would cause imperfect balance, or any injuries that would cause you to look like you were intoxicated?
Do you have a speech impediment or have you attended speech therapy classes?
Was your stomach upset at the time of arrest?
Do you suffer from gastroesophageal reflux disease (GERD)?
Do you suffer from non-alcoholic steatohepatitas (NASH), fatty liver, or any other liver condition/disease or liver enzyme abnormality?
Were you wearing corrective lenses at the time of your arrest?
Diabetes?
Dyslexia?
Anxiety Disorder?
Do you wear dentures/false teeth/braces/other orthodontics or use a retainer?
Do you have or have you been diagnosed with any learning disabilities?
Have you been diagnosed with Attention Deficit Disorder (ADD or ADHD)?
Have you been prescribed any medication(s) for treatment of ADD or ADHD?
Had you taken your ADD/ADHD medication as prescribed on the date of your arrest?
Do you have any difficulties with coordination or balance?
Do you have any Heart diseases?
Do you suffer from any sleep disorders?
After having been arrested for an offense such as yours, most people feel "down" or "depressed." That is a natural feeling. If we accept your case, we will do whatever we reasonably can to alleviate your fears, but we are not skilled or trained in the field of psychology. However, it is still important for us to know how you are feeling since your arrest. Please check all the following that apply:
Do you currently smoke?
Do you smoke?
If you do not currently smoke, have you been a smoker in the past?

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