Were you suffering from any physical problems or past injuries at the time of the arrest? If so, what parts of body?
Explanation of physical problems or old Injuries ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________
➢Ankles ➢Feet
➢Legs ➢Back ➢Knee ➢Hips
__________ __________ __________ __________ __________ __________
Were you receiving any treatment for any of the following neurological conditions at the time of the arrest?
➢Vertigo (Dizzy) ➢Seizure disorder ➢Head injury
➢Nerve damage
➢Learning disability ➢Stroke
➢Depression ➢Sleep Apnea
Please Explain ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________
Do you see a chiropractor regularly? ☐ Yes ☐No
Do you see a psychiatrist/therapist? ☐ Yes ☐No
Do you have respiratory allergies? ☐ Yes ☐ No
Did you have a cold, flu or bronchitis at the time of the arrest? ☐Yes ☐No
Have you been hospitalized in the past? ☐ Yes ☐ No If so, was surgery performed? ☐ Yes ☐ No What surgeries?: ________________________________________________________________________________________________________________________________________
- Follow a pen, finger, or other object with your eyes
- Standing with my head tilted back and eyes closed, feet together
- Standing on one foot for a period of time
- Patting your hands together
- Saying or writing the ABC’s
- Walking a straight line, or heel-to-toe
- Touching your nose with finger
Other:
If 'Other', please indicate what they made you do?
If so, did the officer advise to you that you could refuse the road tests?
If so, what was the result of the test?
What type of shoes were you wearing?
Did you fail to satisfactorily perform the balance and coordination tests as demonstrated to you by the officer?
Describe the area where field sobriety tests were given?
Would you be able to go to and identify the area where field sobriety tests were given?
Would you be able to go to take 10-15 photos during daylight of the area where field sobriety tests were given?
Were you given a roadside handheld breath test?
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