Sheriff's Medical Information (2) Name(Required) First Last Email(Required) Enter Email Confirm Email General Physical ConditionSelect...GoodFairPoorAre you under a doctor's care?Select...YesNoIf yes, why?Do you have any physical limitations that would restrict you from participating in the Sheriff Inmate Labor Detail program?Select...YesNoIf yes, why?Do you have any special medical emergency conditions, (i.e. heart condition, diabetes, epilepsy) please describe:Do you have any allergies?Select...YesNoIf yes, what kind?Are you currently pregnant?Select...YesNoIf yes, how far along?Are you taking any prescribed medication?Select...YesNoIf yes, what kind?If you have any limitations that require light duty work assignments, you are required to provide medical documentation of work restrictions before you can schedule the sentenced SILD. I understand it is my responsibility to inform the SILD office of any changes in my medical situation. The above information is true and accurate to the best of my knowledge. I understand that any false information will result in my removal from the SILD program. Signature BACK TO SIGN-IN