Initial Medical Statement

/ Divide Fire Protection District
PO Box 941 Phone: 719-687-8773
103 Cedar Mountain Rd. Fax: 719-687-9334
Divide, CO 80814 E-Mail:

Initial Medical Statement

Privacy Notice: This information will be kept strictly confidential, and will not be shared with any other party without your consent.

Today’s Date: ___ / ___ / ______

Personal Information:

Legal Name ______

Date of Birth ___ / ___ / ______

Address ______

City ______State ______Zip Code ______

Home Phone ______Work Phone ______Cell Phone ______

Spouse Name ______Ht ______Wt ______Blood Type ______

Emergency Notification Information:

In case of emergency, notify ______

Relationship______Phone ______

Address ______

City ______State ______Zip Code ______

In case of emergency, notify ______

Relationship______Phone ______

Address ______

City ______State ______Zip Code ______

Personal Family Physician Information:

Personal Physician ______

Physician Address ______

City ______State ______Zip Code ______

Phone ______Date of Last Physical/Checkup ______

Medical Problems/Hospitalizations:

Have you been hospitalized, had any surgeries, or seen a physician for anything other than a regular physical/checkup or common cold/flu? Yes _____ No _____

If yes, give dates and details below:

Date(s) ______

Reason(s) ______

______

Medical Problems/Hospitalizations (continued)

Date(s) ______

Reason(s) ______

______

______

Have you experienced any of the following? Check all appropriate box(es):

 Abdominal pain

 Abnormal bleeding

 Allergies

 Anemia

 Arm/leg pain/problems

 Arthritis

 Arrhythmia (irregular heartbeat)

 Asthma

 Back pain or trouble

 Blood loss

 Blood Pressure (high/low)

 Bone or joint deformity

 Breast – mass/pain/problems

 Bronchitis

 Cancer

 Chest pain

 Chicken Pox

 Chronic cough

 Claustrophobia

 Cold or painful fingers

 Depression or excessive worry

 Diabetes

 Dizziness

 Ear or hearing problems (aids)

 Edema (foot/let swelling)

 Epilepsy or seizures

 Emphysema

 Eye trouble/injury (glasses/contacts)

 Fainting spells/unconsciousness

 Fractures (broken bones)

 Gall bladder/stones

 Glaucoma

 Headache, frequent or severe

 Heart condition/problems

 High Blood Pressure

 Hepatitis or liver trouble

 Hernia

 Joint pains/problems/stiffness

 Kidney stones

 Leg cramp/swelling

 Lung or breathing problems

 Memory loss

 Migraine

 Paralysis

 Personality Disorder

 Pneumothorax/Collapsed Lung

 Prostate Symptoms

 Sickle Cell Disease or Trait

 Stroke

 Thyroid trouble

 Tremor of hands or head

 Trouble smelling odors

 Tuberculosis

 Tumors or cysts

Please expand on any positive responses from above ______

______

______

______

______

______

______

______

______

Do you currently have any of the following symptoms of pulmonary or lung illness?

 Shortness of breath

 Shortness of breath when walking fast on level ground or walking up a slight hill or incline

 Shortness of breath when walking with other people at an ordinary pace on level ground

 Have to stop for breath when walking at your own pace on level ground

 Shortness of breath when washing or dressing yourself

 Shortness of breath that interferes with your job

 Coughing that produces Phlegm (thick sputum)

 Coughing that wakes you early in the morning

 Coughing that occurs mostly when you are lying down

 Coughing up blood in the last month

 Wheezing

 Wheezing that interferes with your job

 Chest pain when you breathe deeply

 Any other symptoms that you think may be related to lung problems

Have you ever had any of the following cardiovascular or heart symptoms?

 Frequent pain or tightness in your chest

 Pain or tightness in your chest during physical activity

 Pain or tightness in your chest that interferes with your job

 In the past 2 years, have you noticed your heart skipping or missing a beat

 Heartburn or indigestion that is not related to eating

 Any other symptoms you think may be related to heart or circulation problems

Are there any other medical conditions, or are you taking any medications, that might affect or limit your ability to perform duties within the department? ______

______

______

Are you allergic to any medications? ______

______

______

I certify the above responses are complete, accurate and true to the best of my knowledge. I agree that I will notify Divide Fire in the event my medical situation changes.

Member Signature: ______Date: ______