SMOKE DIVER
Medical Evaluation Form PAGE 1 OF 3
Completed form must be kept on file by the school
Student Information DATE OF EXAM______
(Must be within 1 year of start of class)
Student’s Name: ______Sex: _____Age: ______Date of Birth: ____/____/______
Home Address: ______Home Phone: (______)______
Contact in case of Emergency: ______Relationship to Student: ______
Home No: (_____) ______Work No:(_____) ______Cell: (_____)______
Personal/Family Physician: ______City: ______
State: ______Office Phone: (______) ______
Medical History: MANDATORY (to be completed by student) Explain “yes” answers below. Circle questions you don’t know answers to.
IMPORTANT: IT IS VERY IMPORTANT THAT THESE QUESTIONS ARE ANSWERED TRUTHFULLY AS YOUR SAFETY AND HEALTH IS OF PRIMARY CONCERN. WE CAN NOT QUALIFY ANY STUDENT INTO OUR TRAINING PROGRAM IF THERE IS ANY PRE-EXISTING OR CURRENT MEDICAL CONDITION, INJURY, ILLNESS OR DEFICIENCY WHICH WOULD PROHIBIT YOU FROM PERFORMING THE TYPE OF PHYSICAL ACTIVITITIES YOU WOULD BE ENGAGED IN DURING OUR TRAINING.
YES NO
1. Have you had a medical illness or injury since your last check up or sports physical? ______
2. Do you have ongoing chronic illness? ______
3. Have you ever been hospitalized overnight? ______
4. Have you ever had surgery? ______
5. Are you currently taking any prescription or non-prescription (over-the-counter)
medications, pills or using an inhaler? ______
6. Are you currently taking/have taken any supplements, energy drinks, sport supplements or
vitamins to help you gain or lose weight or improve your preformance? ______
7. Do you have any allergies (for example, pollen, latex, medicine, food or stinging insects)
that require medical treatment? ______
8. Have you ever had a rash or hives develop during or after exercise? ______
9. Have you ever passed out during or after exercise? ______
10. Have you ever had dizziness or fainting spells? ______
11. Have you ever had chest pain during or after exercising? ______
12. Have you ever had racing of your heart or skipped heartbeats? ______
13. Have you had high blood pressure or high cholesterol corrected with meds? Or low blood
pressure corrected with meds? ______
14. Have you ever been told you have a heart murmur? ______
15. Has any family member or relative died of heart problems or sudden death before age 50? ______
16. Has a physician ever denied or restricted your participation in sports for any heart
problems? ______
17. Do you get tired more quickly than your friends do during exercise? ______
18. Have you had a severe viral infection (for example, myocarditis or mononucleosis) within
the last month? ______
PAGE 2 of 2
YES NO
19. Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus,
blisters or pressure sores)? ______
20. Have you ever had a head injury or concussion? ______
21. Have you ever been unconscious or lost your memory? ______
22. Have you ever had seizures, history of epilepsy or neurological disorders? ______
23. Do you have frequent or severe headaches? ______
24. Have you ever had numbness or tingling in your arms, hands, legs or feet? ______
25. Have you ever become ill from exercising in the heat or have ever had a heat related injury? ______
26. Do you cough, wheeze or have trouble breathing during or after activity? ______
27. Do you have asthma, chronic bronchitis or lung disease? ______
28. Have you had any problems with your eyes or vision? ______
29. Do you wear glasses, contacts or protective eyewear? ______
30. Have you ever had stomach, renal, liver or intestinal problems? ______
31. Have you broken or fractured any bones or dislocated any joints? ______
If yes, check appropriate blank and explain below:
____ Head ____ Elbow ____ Hip
____ Neck ____ Forearm ____ Thigh
____ Back ____ Wrist ____ Knee
____ Chest ____ Hand ____ Shin/Calf
____ Shoulder ____ Finger ____ Ankle
____ Upper Arm ____ Foot
32. Do you want to weigh more or less than you do now? ______
33. Do you feel stressed out? ______
34. Have you ever been diagnosed with Sickle Cell Anemia or any other blood
Related disorder? ______
35. Have you ever been diagnosed with Sickle Cell? ______
36. Are you pregnant?
37. DPT/DT/TD/Tetanus (Tetanus immunization current within the last five years)
Date of last Tetanus:______
Explain “yes” answers here:
______
______
______
______
List all medications you are currently taking:
______
Student Signature: ______Date: ______
PHYSICAL EVALUATION PAGE 3 of 3
PHYSICAL EXAMINATION
(To be completed by licensed MD ONLY!!!!)
Examination should include but is not limited to:
Dermatological system, cardiovascular system Genitourinary system
Stress test and evaluation of 12 Lead EKG Neurological system
Systolic and Diastolic Blood pressure Musculoskeletal system
Respiratory system Ears, eyes, nose, mouth and throat
Gastrointestinal system Far visual acuity corrected or uncorrected
Endocrine and metabolic system Peripheral vision
Blood work Labs (CBC,BMP) minimum Urinalysis
Applicant Name:______Date of Birth: ______
Height: ______Weight: ______% Body Fat:______
Blood Pressure: ______/______(______/______, ______/______) Pulse: ______
Visual Acuity: Right 20/_____ Left 20/_____ Corrected: Yes No Pupils: Equal_____ Unequal _____
MEDICAL FINDINGS
Musculoskeletal
1. Appearance ______10. Neck ______
2. Eyes/Ears/Nose/Throat ______11. Back ______
3. Lymph Nodes ______12. Shoulder/Arm ______
4. Heart ______13. Elbow/Forearm ______
5. Pulse ______14. Wrist/Hand ______
6. Lungs ______15. Hip/Thigh ______
7. Abdomen ______16. Knee ______
8. Genitalia (males only) ______17. Leg/Ankle ______
9. Skin ______18. Foot ______
Any other additional findings?______
______
For the medical professional conducting the examination to complete:
Has no pre-existing or current condition, Has a pre-existing or current condition, illness
illness, injury or deficiencies. injury or deficiency that presents a safety or
The applicant is medically fit to engage health risk in the environment or job functions
in Firefighting Smoke Diver training. of a firefighter. The applicant is not medically
fit for Firefighting Smoke Diver training.
Completed Required (Please print)
Physician’s Signature: ______Date signed: ______
Address: ______Telephone: ______
______JPB 6/29/2013