Bloom Occupational Health Software

You are about to complete a questionnaire for your annual incumbent Fire Fighter physical exam. Your answers will be kept confidential. We encourage you to be as honest as possible. The medical provider will use your answers to develop your annual plan of action for your health and your continued safety on the job. Our questions are derived from several sources, all of which are endorsed by the NFPA, IAFC, and IAFF.

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For the following questions, please select the option that most accurately applies to you over the past week.

I found myself getting upset by quite trivial things. *

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I was aware of dryness of my mouth. *

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I couldn't seem to experience any positive feeling at all. *

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I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion). *

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I just couldn't seem to get going. *

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I tended to over-react to situations. *

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I had a feeling of shakiness (eg, legs going to give way). *

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I found it difficult to relax. *

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I found myself in situations that made me so anxious I was most relieved when they ended. *

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I felt that I had nothing to look forward to. *

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I found myself getting upset rather easily. *

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I felt that I was using a lot of nervous energy. *

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I felt sad and depressed. *

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I found myself getting impatient when I was delayed in any way (eg, elevators, traffic lights, being kept waiting). *

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I had a feeling of faintness. *

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I felt that I had lost interest in just about everything. *

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I felt I wasn't worth much as a person. *

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I felt that I was rather touchy. *

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I perspired noticeably (eg, hands sweaty) in the absence of high temperatures or physical exertion. *

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I felt scared without any good reason. *

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I felt that life wasn't worthwhile. *

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I found it hard to wind down. *

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I had difficulty in swallowing. *

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I couldn't seem to get any enjoyment out of the things I did. *

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I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat). *

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I felt down-hearted and blue. *

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I found that I was very irritable. *

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I felt I was close to panic. *

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I found it hard to calm down after something upset me. *

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I feared that I would be "thrown" by some trivial but unfamiliar task. *

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I was unable to become enthusiastic about anything. *

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I found it difficult to tolerate interruptions to what I was doing. *

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I was in a state of nervous tension. *

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I felt I was pretty worthless. *

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I was intolerant of anything that kept me from getting on with what I was doing. *

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I felt terrified. *

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I could see nothing in the future to be hopeful about. *

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I felt that life was meaningless. *

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I found myself getting agitated. *

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I was worried about situations in which I might panic and make a fool of myself. *

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I experienced trembling (eg, in the hands). *

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I found it difficult to work up the initiative to do things. *

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These questions are related to how you have reacted to stressful events. In the past month, how much were you bothered by:

Repeated, disturbing, and unwanted memories of a stressful experience? *

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Repeated, disturbing dreams of a stressful experience? *

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Suddenly feeling or acting as if a stressful experience were actually happening again (as if you were actually back there reliving it)? *

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Feeling very upset when something reminded you of a stressful experience? *

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Having strong physical reactions when something reminded you of a stressful experience (for example, heart pounding, trouble breathing, sweating)? *

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Avoiding memories, thoughts, or feelings related to a stressful experience? *

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Avoiding external reminders of a stressful experience (for example, people, places, conversations, activities, objects, or situations)? *

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Trouble remembering important parts of the stressful experience? *

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Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? *

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Blaming yourself or someone else for a stressful experience or what happened after it? *

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Having strong negative feelings such as fear, horror, anger, guilt, or shame? *

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Loss of interest in activities that you used to enjoy? *

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Feeling distant or cut off from other people? *

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Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? *

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Irritable behavior, angry outbursts, or acting aggressively? *

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Taking too many risks or doing things that could cause you harm? *

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Being “superalert” or watchful or on guard? *

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Feeling jumpy or easily startled? *

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Having difficulty concentrating? *

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Trouble falling or staying asleep? *

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How likely are you to doze off or fall asleep in the following situations? You should rate your chances of dozing off, not just feeling tired. Even if you have not done some of these things recently try to determine how they would have affected you.:

Sitting and reading *

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Watching TV *

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Sitting inactive in a public place (e.g., a theater or a meeting) *

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As a passenger in a car for an hour without a break *

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Lying down to rest in the afternoon when circumstances permit *

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Sitting and talking to someone *

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Sitting quietly after a lunch without alcohol *

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In a car, while stopped for a few minutes in traffic *

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Please review all fields and confirm they are correct.

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