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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If you currently use any tobacco products, what kind(s) do you use? *
  • Cigarettes
  • Cigars
  • Pipe
  • Chew
  • No Tobacco

 

   

 

 


 

 

 


 


 

Please indicate if and when you were diagnosed with the following health issues and whether you are currently experiencing the issue.

  • Diabetes Type 1

  • Diabetes Type 2

  • Hypertension

  • Hyperlipidemia

  • Cancer

  • Heart Disease

  • Respiratory Disease

  • Gastrointestinal Disease

  • Reproductive Health

  • Neurologic Disease

  • Hepatitis

  • Allergies

  • Psychiatric Disorder

  • Shoulder Injury

  • Knee Injury

  • Back Injury/Disease

  • Arthritis

  • Other
  • Additional Information or Medications:

Which, if any, of the following surgeries have you had?

  • Chest:

  • Back:

  • Neck:

  • Shoulder:

  • Knee:

  • Hip:

  • Leg:

  • Ankle:

  • Foot:

  • Other:

Please indicate which screening tests you've had in the last year and whether the results were normal.

  • PSA(Prostate Specific Antegen):

  • Testicular:

  • DRE(Digital Rectal Exam):

  • FOB(Fecal Occult Blood):

  • Colonoscopy:

  • Pap Smear:

  • Breast:

  • Mammogram:

  • Skin:

  • Other:

   

   

   

   


Please review all fields and confirm they are correct.

Congratulations, you have registered successfully!