This form contains 74 fields organized into 26 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Additional Comments
Additional Comments	Text	Provide any additional comments or information not covered elsewhere in the form.
Alcohol Consumption
Daily Alcoholic Beverages	Text	Enter the number of alcoholic beverages consumed daily.
Applicant Information
Applicant Name	Text	Provide the full name of the applicant, including first, middle, and last names.
Applicant Date of Birth	Date	Provide the applicant's date of birth.
Certification
Applicant Signature	Text	Please provide the applicant's signature.
Certification Date	Date	Please enter the date of certification.
Comments
Comment 1	Text	Provide any additional comments or explanations in this field.
Comment 2	Text	Provide any additional comments or explanations in this field.
County/Agency
County/Agency Name	Text	Provide the name of the county or agency.
Current and/or Past Diagnosis
Heart Disease	CheckBox
Impaired Sight	Checkbox	Check this box if you have been diagnosed with Impaired Sight within the last five years.
Orthopedic Problems	Checkbox	Check this box if you have been diagnosed with Orthopedic Problems within the last five years.
Cancer	Checkbox	Check this box if you have been diagnosed with Cancer within the last five years.
Heredity Conditions	Checkbox	Check this box if you have been diagnosed with Heredity Conditions within the last five years.
Chronic Medical Conditions	Checkbox	Check this box if you have been diagnosed with Chronic Medical Conditions within the last five years.
Diabetes	Checkbox	Check this box if you have been diagnosed with Diabetes within the last five years.
Hypertension	Checkbox	Check this box if you have been diagnosed with Hypertension within the last five years.
Mental Illness	Checkbox	Check this box if you have been diagnosed with Mental Illness within the last five years.
Impaired Hearing	Checkbox	Check this box if you have been diagnosed with Impaired Hearing within the last five years.
Allergies	Checkbox	Check this box if you have been diagnosed with Allergies within the last five years.
Respiratory Condition	Checkbox	Check this box if you have been diagnosed with a Respiratory Condition within the last five years.
Seizure Disorder	Checkbox	Check this box if you have been diagnosed with a Seizure Disorder within the last five years.
Heart Attack	Checkbox	Check this box if you have been diagnosed with a Heart Attack within the last five years.
Stroke	Checkbox	Check this box if you have been diagnosed with a Stroke within the last five years.
Kidney Disease	Checkbox	Check this box if you have been diagnosed with Kidney Disease within the last five years.
Thyroid Disease	Checkbox	Check this box if you have been diagnosed with Thyroid Disease within the last five years.
Chronic Pain	Checkbox	Check this box if you have been diagnosed with Chronic Pain within the last five years.
Autoimmune Disease	Checkbox	Check this box if you have been diagnosed with an Autoimmune Disease within the last five years.
Other Condition or Injury:	Checkbox	Check this box if you have been diagnosed with any other condition or injury not listed within the last five years.
Other Condition or Injury	Text	Specify any other condition or injury not listed in the provided options.
Fifth Medication
Fifth Medication Name	Text	Enter the name of the fifth medication.
Fifth Medication Dosage and Frequency	Text	Enter the dosage and frequency of the fifth medication.
Fifth Medication Condition Prescribed For	Text	Enter the medical condition for which the fifth medication was prescribed.
First Medication
First Medication Name	Text	Enter the name of the first medication.
First Medication Dosage and Frequency	Text	Provide the dosage and frequency for the first medication.
First Medication Condition	Text	State the condition for which the first medication was prescribed.
First Surgery/Hospital Stay
First Surgery/Hospitalization Type	Text	Provide the type of the first surgery or the reason for the first hospitalization.
First Surgery/Hospitalization Year	Text	Provide the approximate year of the first surgery or hospitalization.
Fourth Medication
Fourth Medication Name	Text	Enter the name of the fourth medication being taken.
Fourth Medication Dosage and Frequency	Text	Enter the dosage and frequency of the fourth medication.
Fourth Medication Condition	Text	Enter the condition for which the fourth medication was prescribed.
Fourth Surgery/Hospital Stay
Fourth Surgery Type or Hospitalization Reason	Text	Enter the type of the fourth surgery or the reason for the fourth hospitalization.
Fourth Surgery/Hospitalization Year	Number	Enter the approximate year of the fourth surgery or hospital stay.
General
Additional Comments:_Line 1	Text
Additional Comments:_Line 2	Text
Additional Comments:_Line 3	Text
Last Physical Exam Date
Last Physical Exam Date	Date	Enter the date of your last physical examination.
Licensed Health Professionals
Licensed Physician Professional	Text	Provide the name, address, and telephone number of the current licensed physician professional.
Licensed Specialist Professional	Text	Provide the name, address, and telephone number of the current licensed specialist professional.
Licensed Other Professional	Text	Provide the name, address, and telephone number of the current licensed other professional.
Patient Signature and Date
Patient Signature	Text	Enter the patient's signature.
Signature Date	Date	Enter the date the patient signed.
Physical Activity Restrictions
Physical Activity Restrictions	Text	Enter any limits or restrictions on physical activity.
Physician's Care Status
Physician's Care Status Details	Text	Provide details regarding your current physician's care status for any of the diagnoses or injuries listed above.
Release of Information Authorization
Authorizing Doctor's Name	Text	Enter the name of the doctor being authorized to release medical information.
Authorizing County/Agency	Text	Enter the name of the county or agency to whom the medical information is being released.
Second Medication
Second Medication Name	Text	Enter the name of the second medication being taken.
Second Medication Dosage and Frequency	Text	Enter the dosage and frequency for the second medication.
Second Medication Condition	Text	Enter the condition for which the second medication was prescribed.
Second Surgery/Hospital Stay
Second Surgery Type/Reason	Text	Enter the type of surgery or reason for the second hospitalization.
Second Surgery Year	Text	Enter the approximate year of the second surgery or hospital stay.
Seventh Medication
Seventh Medication Name	Text	Enter the name of the seventh medication.
Seventh Medication Dosage and Frequency	Text	Enter the dosage and frequency of the seventh medication.
Seventh Medication Condition Prescribed For	Text	Enter the condition for which the seventh medication was prescribed.
Sixth Medication
Sixth Medication Name	Text	Please enter the name of the sixth medication.
Sixth Medication Dosage and Frequency	Text	Please enter the dosage and frequency for the sixth medication.
Sixth Medication Condition Prescribed For	Text	Please enter the medical condition for which the sixth medication was prescribed.
Third Medication
Third Medication Name	Text	Enter the name of the third medication.
Third Medication Dosage and Frequency	Text	Enter the dosage and frequency for the third medication.
Third Medication Condition	Text	Enter the medical condition for which the third medication was prescribed.
Third Surgery/Hospital Stay
Third Surgery/Hospital Stay Type	Text	Enter the type of the third surgery or the reason for the third hospital stay.
Third Surgery/Hospital Stay Year	Text	Enter the approximate year of the third surgery or hospital stay.
Tobacco Usage
Number of Cigarettes smoked	Text	Max length: 3 characters
Number of packs per day	Text

California Department of Social Services Form RFA 07 (2/18), Resource Family Approval (RFA) Health Questionnaire (Mandatory) Instructions