SOP 210.03-att-3: Medical Checklist for Screening Prospective Participants in the Detention Center and Probation Boot Camp Program

SOP IIB12-0003

(210.03)
Attachment 3
07/15/15
MEDICAL CHECKLIST FOR SCREENING
PROSPECTIVE PARTICIPANTS IN THE DETENTION CENTER
AND PROBATION BOOT CAMP PROGRAM

Offender's Name:_____________________________________________________

Social Security Number: _______________________________________________

Date of Birth:_________________________________________________________

Instructions

This document is applicable to both the Probation Detention Center and Probation Boot
Camp programs. The purpose of the document is slightly different when applied to the
individual program.

For Detention Centers, use of pages 2 and 3 is all that is necessary. It is very helpful for the
Center to be alerted to any serious medical problems prior to the arrival of the probationer.

Georgia law (42-8-35.1) gives the department the authority to determine if the probationer is
physically and mentally suitable for the Boot Camp program. Therefore, it may be necessary
and helpful to complete all relevant sections of the form so that an appropriate decision can be
made. NOTE: Having one of the medical problems identified does not necessarily disqualify
a probationer from Boot Camp participation.

If any candidate for Detention Center or Boot Camp has a known significant health problem,
this information should be shared at the time of referral. Please remember that in the Boot
Camp program, the candidate may be rejected if found to be physically or mentally unfit for
the program.

The medical staff at the Detention Center and Boot Camp may be contacted for assistance.

Page 1 of 8
PART I - PARTICIPANTS HEALTH HISTORY
In the past or present does the candidate have a history of any of the following:

Condition Yes No Comments
1. Diabetes ___ ___ __________

2. Epilepsy/Seizures ___ ___ __________

3. Kidney Disease ___ ___ __________

4. Hypertension (High Blood Pressure) ___ ___ __________

5. Heart Murmur/Heart Problems ___ ___ ___________

6. Asthma/Chronic Bronchitis/Emphysema ___ ___ ___________

7. Hepatitis ___ ___ ___________

8. Tuberculosis ___ ___ ___________

9. Allergies, i.e., dust, trees, foods ___ ___ ___________

10. Surgery ___ ___ ___________

11. Hearing Loss ___ ___ __________

12. Loss of Limb ___ ___ __________

13. Vision ___ ___ __________

14. Bone/Joint Defects ___ ____ __________

15. Back Problems ___ ____ __________

16. Psychological Problems ___ ____ __________

17. Special Diet ___ ____ __________

18. AIDS Test Result Positive ___ ____ __________

19. Hospitalized for medical or psychiatric
treatment in the past six months? For
what reason? ____ ____ _________
20. Any significant observations regarding
physical or mental health of the probationer? ____ ____ _________

Page 2 of 8

PART II - INTERVIEWER OBSERVATIONS & MISCELLANEOUS INFORMATION

Question Yes No Comments

1. Does the candidate wear eye glasses or ___ ___ __________
contact lens?

(If accepted into the program, he must
bring his glasses and/or contact lens
with him.)

2. Does he exhibit any visible signs of
trauma, illness, limp, pain, limita-
tions, or movement? ___ ___ __________

3. Does he exhibit any signs of drug or
alcohol withdrawal? ___ ___ __________

4. Does he exhibit any signs of emotional
disorders, excessive depression, or
incoherent? ___ ___ ___________

5. Does he exhibit any symptoms or need
for immediate medical or dental care? ___ ___ ___________

6. Does he have any allergies to
medications? Which medications? ____ ____ _________

If he is unsure, he should check with
his family.

7. Has this person attempted suicide in the past? ____ ____ __________

Page 3 of 8
ATTACHMENT I

ADDITIONAL QUESTIONS TO ASK FOR "YES" RESPONSES

PART I

(If any of the following questions are answered "yes" or if you have additional questions or
concerns that need a medical opinion, you should call the medical staff at the center for
assistance in determining suitability for admission.)

1. Diabetes:

Is the candidate insulin dependent?

Is the candidate not stable on an oral hypoglycemic medication?

2. Epilepsy/Seizure (fits, seizures): (If there has been a history of seizure but not one
within the last year and the candidate is not on medication, he is eligible for the
program.)

Has the candidate had a seizure in the last year? Cause of seizure?

Is the candidate taking medication for this disorder at the present time?

Is the candidate under the care of a physician at the present time?

3. Kidney Disease:

Does the candidate have a history of glomerulonephritis or protein in the urine?

Does the candidate have a history of acute or chronic kidney failure?

Page 4 of 8

Does the candidate have a history of ureteral stone (kidney stones)?

4. Hypertension:

Is the candidate taking medication?

What medication?

5. Heart Murmur/Heart Problems:

What type of heart murmur or heart problem exists?

Is the candidate currently taking medication?

6. Asthma/Chronic Bronchitis/Emphysema:

How long has the candidate had this condition?

What are the limitations of activity?

What medications is he taking?

7. Hepatitis:

When did he have hepatitis?

Was it hepatitis A, B, or non-A, non-B? (Any past or current history of hepatitis
requires a blood test to determine the type of hepatitis.)

Is he still under a physician's care for hepatitis?

Page 5 of 8

8. Tuberculosis:

How long has this condition existed?

What medications is he taking for it?

What were the results of the chest x-ray?

Is the candidate taking INH medication for a positive PPD?

9. Allergies, e.g., dust, trees, grasses, foods, grease, etc.:

What allergies do you have?

What do you do when you have a "bad" allergy?

What medications do you take for allergies? (The need for a special diet would not
prohibit a candidate from being eligible for the program. The institution, however,
does need to know this information prior to his arrival.)

Are there any restrictions regarding environment or activity because of the allergies?
What are they? (The "key" is whether they are related to activities in which the
candidate would be participating and whether they are under a physician's care.)

Page 6 of 8

10. Surgery:

Any previous surgery that would prohibit strenuous activity? Which activities? When
was the surgery performed?

11. Hearing Loss:

Do you have a hearing loss in both ears that requires constant use of hearing aids?
(The key is constant use of hearing aids. If they were lost or forgotten, the person
could be endangered.)

12. Loss of Limb:

Has there been the loss of any limb which would prohibit doing strenuous activity, i.e.,
assigned details? Which activities?

13. Vision: (Note: If they wear glasses or contacts, they must bring them when they enter
the program.)

Any vision worse than 20/50 in both eyes and/or not corrected by glasses. (If you have
any questions, call the medical unit in the boot camp.)

14. Bones/Joint Defects:

Any current or past problems which would prohibit strenuous activity, i.e. assigned
details? Which activities?

15. Back Problems:

Any current or past problems which would prohibit strenuous activity, i.e., assigned
details? Which activities?

Page 7 of 8

Is or was he under a physician's care for the back problems? (If he is or was not under
a physician's care, consider him eligible for the program.)

15. Psychological Problems:

Past hospitalization? Reason? When? For how long?

Is he currently under treatment for a mental problem? What problem? Where is he
being treated?

Is he currently taking medication? If so, what medications?

Is or has the candidate been treated for alcohol or drug abuse? When? Where?
(Consider the length of time in jail because if they have been in jail for 30 days or
more, they may have dried out in jail.)

Was the candidate ever in a special class in grammar, middle, or high school? If so,
what kind of special class and for what reason?

17. Special Diet: (It would be a rare occasion in which need for a special diet could
eliminate a candidate from being eligible for the program. This information is needed
prior to the candidate's arrival at the center and the center will be so notified when
this checklist is sent to the receiving center prior to the candidate's arrival as
required.)

Page 8 of 8

Any medical or dental reasons which would require a special diet? What reason for
the diet? What type of special diet? How long will he need to be on this diet?

18. Positive AIDS Test Results: (Positive test does not necessarily eliminate a boot camp
candidate, but need to determine if the person is actually ill at this time.)

19. Hospitalization: (The purpose of this question is to determine if there were
hospitalizations that the candidate may not have thought of in the context of the other
questions.)

Has the candidate been hospitalized for medical or psychiatric treatment in the past
six months? Describe reason for hospitalization and the length of time hospitalized.

RETENTION SCHEDULE:

Upon completion of this form, it will be placed in the inmate/probationer's case history

file.