SP4419 Medical Examination Report (Enforcement Cadet)
MEDICAL EXAMINATION REPORT
Wisconsin Department of Transportation
SP4419 9/2014
The Wisconsin Law Enforcement Standards Board, under LES 2.01(f)(1)(2), requires that a peace officer candidate be examined by a licensed physician or surgeon to ensure that the applicant is free of any physical defect or medical condition which might adversely affect job performance.
This form is designed to be used in conjunction with the Medical History Statement (Form SP4414) to evaluate an applicant's qualifications for the position of Wisconsin State Patrol Trooper/Inspector. Both forms concentrate only on those areas which have been determined to be medically related to the requirements of a Wisconsin State Patrol officer. Please review the Medical History Statement before examining the candidate.
|Legal Name: Last |First |Middle |Birth Date (m/d/yyyy) |Sex |
| | | | |Male Female |
|Height (without shoes) |Weight (without shoes or coat) |
| (Ft/Inches) | (Lb/Kg) |
VITAL SIGNS
|Blood Pressure (sitting) |Pulse |Resp. |Temperature |
| Right or Left Arm |Rate Rhythm | | |
|NORMAL / ABNORMAL |CHECKLIST |DETAILED DESCRIPTION OF ABNORMAL FINDINGS |
|Hands/Skin |Hands/Skin | |
|Normal / Abnormal |Hair | |
|Normal / Abnormal |Skin/Color/Texture | |
| |(Lesions, Scars) | |
|Normal / Abnormal |Nails | |
|Head/Eyes |Head/Eyes | |
|Normal / Abnormal |Configuration | |
|Normal / Abnormal |Lids | |
|Normal / Abnormal |Conj/Sclers | |
|Normal / Abnormal |Pupils/Equal | |
|Normal / Abnormal |Light Reaction | |
|Normal / Abnormal |Fundi (Undilated Eyes) | |
|Normal / Abnormal |EOM | |
|Ears/Nose/Throat/Mouth |Ears/Nose/Throat/Mouth | |
|Normal / Abnormal |Pinna/Canals/TM | |
|Normal / Abnormal |Nasal Septum/Mucosa | |
|Normal / Abnormal |Teeth/Gums | |
|Normal / Abnormal |Tongue/Palate | |
|Normal / Abnormal |Tonsils/Pharynx | |
|Neck/Nodes |Neck/Nodes | |
|Normal / Abnormal |Bruit | |
|Normal / Abnormal |ROM | |
|Normal / Abnormal |Muscle Strength | |
|Normal / Abnormal |Thyroid | |
|Normal / Abnormal |Neck Nodes | |
|Normal / Abnormal |Inguinal/Auxillary Nodes | |
MEDICAL EXAMINATION REPORT (continued) Wisconsin Department of Transportation
SP4419
|NORMAL / ABNORMAL |CHECKLIST |DETAILED DESCRIPTION OF ABNORMAL FINDINGS |
|Chest/Lungs |Chest/Lungs | |
|Normal / Abnormal |Shape/Symmetry/ Diaphragmatic | |
|Normal / Abnormal |Excursion | |
|Normal / Abnormal |Auscultation | |
|Normal / Abnormal |Breasts (Discharge/Masses) | |
|Cardiovascular |Cardiovascular | |
|Normal / Abnormal |Carotids | |
|Normal / Abnormal |Neck Veins | |
|Normal / Abnormal |Pulses: Radial | |
|Normal / Abnormal |D. Pedis | |
|Normal / Abnormal |Heart Sounds (Murmurs) | |
|Abdomen |Abdomen | |
|Normal / Abnormal |Hernia | |
|Normal / Abnormal |Shape | |
|Normal / Abnormal |Bowel Sounds (Bruits) | |
|Normal / Abnormal |Liver/Spleen | |
|Normal / Abnormal |Masses | |
|Musculoskeletal/Extremities |Musculoskeletal/Extremities | |
|Normal / Abnormal |Spine | |
|Normal / Abnormal |Extremities (Edema/Varicosities) | |
|Normal / Abnormal |Joints | |
|Normal / Abnormal |ROM | |
|Nervous System |Nervous System | |
|Normal / Abnormal |CN | |
|Normal / Abnormal |Motor | |
|Normal / Abnormal |Sensory | |
|Normal / Abnormal |Cerebellar | |
|Normal / Abnormal |Reflexes | |
|Genitalia/Rectal |Genitalia/Rectal | |
|Normal / Abnormal |Male: Penis | |
|Normal / Abnormal |Scrotum/Testes | |
|Normal / Abnormal |Hernia | |
|Normal / Abnormal |Prostate | |
| | | |
|Normal / Abnormal |Female: Perineum/Vagina | |
|Normal / Abnormal |Cervix/Uterus/Adnexa | |
LABORATORY FINDINGS
|Urine Dip |
|Protein |Specific Gravity |Glucose |
| | | |
MEDICAL EXAMINATION REPORT (continued) Wisconsin Department of Transportation
SP4419
VISION
|Visual Acuity (If applicant wears glasses, test and record acuity both with and without glasses.) |
|Without Correction |R20/ |L20/ |B20/ |
|With Correction |R20/ |L20/ |B20/ |
|Depth Perception |Color Perception |Tonometry |
| | | |
FORM FIELDS OF VISION (Temporal)
Record degrees of temporal fields obtained by confrontations in space and on diagram
|Right Eye |Left Eye |
| | |
|(Eye on Zero Line) |(Eye on Zero Line) |
MEDICAL FINDINGS/OPINION
No Yes Based on your examination, information supplied on the medical history statement, and any other information obtained and considered, it there any physical or medical condition which in your opinion, would substantially impair this person's ability to fully perform as a State Patrol Trooper/Inspector?
(If yes complete the following. Attach additional sheets if needed.)
|Medical Condition or Disease |
| |
|Any Qualifying Statements - Related or Additional Circumstances |
| |
|Rationale for decision, including job behavior affected |
| |
| |X | |
| |(Examining Physician Signature) |(Date – m/d/yy) |
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