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):













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.





























Please review all fields and confirm they are correct.

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