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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In the past, have you ever(check all that apply):

Tried to Cut down or Change your pattern of drinking or drug use?
Been Annoyed or Angry because of others’ concern about your drinking or drug use?
Felt Guilty about the consequences of your drinking or drug use?
Had a drink or used a drug in the morning (as an “Eye-opener”) to decrease hangover or withdrawal symptoms?

How often did you have a drink containing alcohol in the past year? *

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How many drinks did you have on a typical day when you were drinking in the past year? *

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How often did you have six or more drinks on one occasion in the past year? *

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How often during the last year have you found that you were not able to stop drinking once you had started? *

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How often during the last year have you failed to do what was normally expected from you because of drinking? *

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How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? *

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How often during the last year have you had a feeling of guilt or remorse after drinking? *

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How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

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Have you, or has someone else, been injured as a result of your drinking? *

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Has a relative or friend, or a doctor or other health worker, been concerned about your drinking or suggested you cut down? *

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Directions: The following questions concern information about your involvement with drugs. Drug abuse refers to (1) the use of prescribed or “over-the-counter” drugs in excess of the directions, and (2) any non-medical use of drugs. Consider the past year (12 months) and carefully read each statement. Then decide whether your answer is YES or NO and select the appropriate response. Please be sure to answer every question.

Have you used drugs other than those required for medical reasons? *

Yes

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Have you abused prescription drugs? *

Yes

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Do you abuse more than one drug at a time? *

Yes

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Can you get through the week without using drugs(other than those required for medical reasons)? *

Yes

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Are you always able to stop using drugs when you want to? *

Yes

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Do you abuse drugs on a continuous basis? *

Yes

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Do you try to limit your drug use to certain situations? *

Yes

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Have you had “blackouts” or “flashbacks” as a result of drug use? *

Yes

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Do you ever feel bad about your drug abuse? *

Yes

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Does your spouse (or parents) ever complain about your involvement with drugs? *

Yes

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Do your friends or relatives know or suspect you abuse drugs? *

Yes

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Has drug abuse ever created problems between you and your spouse? *

Yes

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Has any family member ever sought help for problems related to your drug use? *

Yes

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Have you ever lost friends because of your use of drugs?*

Yes

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Have you ever neglected your family or missed work because of your use of drugs? *

Yes

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Have you ever been in trouble at work because of drug abuse? *

Yes

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Have you ever lost a job because of drug abuse? *

Yes

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Have you gotten into fights when under the influence of drugs? *

Yes

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Have you ever been arrested because of unusual behavior while under the influence of drugs? *

Yes

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Have you ever been arrested for driving while under the influence of drugs? *

Yes

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Have you engaged in illegal activities in order to obtain drug? *

Yes

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Have you ever been arrested for possession of illegal drugs? *

Yes

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Have you ever experienced withdrawal symptoms as a result of heavy drug intake? *

Yes

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Have you had medical problems as a result of your drug use(e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? *

Yes

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Have you ever gone to anyone for help for a drug problem? *

Yes

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Have you ever been in a hospital for medical problems related to your drug use? *

Yes

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Have you ever been involved in a treatment program specifically related to drug use? *

Yes

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Have you been treated as an outpatient for problems related to drug abuse? *

Yes

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Please review all fields and confirm they are correct.

I confirm that I am the person listed in this form and that the information is correct to the best of my knowledge. Please agree to the terms.

Congratulations, you have successfully completed this form.