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SECTION 4.C. MEDICATION <br /> NO YES HAVE YOU EVER BEEN PRESCRIBED MEDICATION TO HELP YOU DEAL WITH <br /> EMOTIONAL OR PSYCHOLOGICAL DISTRESS? INCLUDE DRUGS PRESCRIBED BY YOUR <br /> PERSONAL PHYSICIAN IF THEY WERE FOR PSYCHOLOGICAL SYMPTOMS OR TO IMPROVE <br /> GENERAL FUNCTIONING. <br /> IF YES, PLEASE INDICATE ANY MEDICATION(S)YOU HAVE EVER BEEN PRESCRIBED: <br /> NO YES ANTI-DEPRESSANT OR MOOD ELEVATORS (SUCH AS PROZAC, <br /> AMITRIPTYLINE) <br /> NO YES TRANQUILIZERS(BARBITURATES,VALIUM, LIBRIUM, STELAZINE <br /> NO YES MOOD STABILIZERS (SUCH AS LITHIUM, TEGRETOL, ETC <br /> NO YES SLEEPING PILLS(HALCYON, ETC.) <br /> NO YES MEDICATION TO CONTROL PANIC ATTACKS <br /> NO YES MEDICATION TO CONTROL ANXIETY <br /> NO YES MEDICATION TO CONTROL OBSESSIVE-COMPULSIVE BEHAVIOR <br /> NO YES MEDICATION TO TREAT LEARNING DISABILITIES AND RELATED PROBLEMS SUCH <br /> AS HYPERACTIVITY,ATTENTION DEFICIT DISORDER (ADD),AND ATTENTION <br /> DEFICIT HYPERACTIVITY DISORDER(ADHD) (RITALIN, ETC) <br /> NO YES MEDICATION TO CONTROL SEVERE HEADACHES <br /> NO YES MEDICATION TO CONTROL SEIZURES <br /> NO YES ANY OTHER MEDICATION TO DEAL WITH PSYCHOLOGICAL DISTRESS <br /> NO YES HAVE YOU EVER BEEN DEPENDENT ON, OR ADDICTED TO,ANY <br /> PRESCRIPTION MEDICATION? <br /> IF YOU ANSWERED YES TO ANY OF THE ABOVE, IDENTIFY DRUG AND WHAT PERIOD OF TIME (YEAR, <br /> MONTH), AND WHEN LAST USED IN SPACE BELOW. <br /> NAME OF MEDICATION Year first used Year last used Total times used <br /> SECTION 5. MISCELLANEOUS <br /> NO YES DO YOU HAVE ANY TATTOOS? IF YOU HAVE ONE OR MORE TATTOOS ANSWER THE <br /> FOLLOWING QUESTIONS. <br /> How MANY TATTOOS DO YOU HAVE? DESCRIBE EACH TATTOO: <br /> ARE ANY OF YOUR TATTOOS VISIBLE TO OTHER PEOPLE IF YOU ARE ONLY WEARING SHORTS AND A T- <br /> SHIRT? <br /> APPLICANT'S CERTIFICATION <br /> I hereby certify that the information provided by me in response to all of the questions in this <br /> questionnaire is true and accurate. I am aware that providing false information during the <br /> application process may be grounds for my rejection during the selection process, or <br /> termination after employment if falsification is discovered later. <br /> Applicant Signature Date <br /> TURN PAGE OVER ►►► ►► <br /> PSS/CEPS PLLC(c)Law Enforcement Psychological Services, Inc. (408) 356-9696 <br /> 54 <br />