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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Access Code: *

First Name: *

Middle Name: *

Last Name: *

Employee ID *:

Email Address *:

Phone Number *:

Date of birth *:

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Specify your gender *:

Ethnicity *:

Marital Status *:

Highest Educational Level *:

Employer *:

Employer City *:

Are you currently employed as a firefighter? *

Year Retired: *

Year of Hire: *

Have you ever left for more than 6 months? *

How many months? *

Do you currently work another job? *

How many hours/week? *

Current Primary Assignment:

Assigned Since (Year):

How many stations have you been assigned to for more than one year? *

Estimated Non Work-Related Sick Days In Last Year: *

Estimated Injury Hours In Last Year: *

Light Duty Days: *

In the last year, have you been placed on permanent alternative duty? *

If so, when did the permanent alternative duty begin? *

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July 2025
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27	29	30	1	2	3	4	5
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29	13	14	15	16	17	18	19
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31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

In the last year, have you been placed on long-term alternative duty? *

If so, when did the long-term alternative duty begin (approximate date)? *

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July 2025
	S	M	T	W	T	F	S
27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
30	20	21	22	23	24	25	26
31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

Number of Months on Long-Term alternative duty: *

Have you smoked at least 100 cigarettes in your life? *

How many cigarettes do (or did you) you smoke a day? *
For how many years have you smoked (or did you smoke) this amount? *
How often do you smoke now? *

If you currently use any tobacco products, what kind(s) do you use? *

Cigarettes
Cigars
Pipe
Chew
No Tobacco

During the last year, have you stopped using tobacco for one day or longer while trying to quit? *

If so, for how many days? (Enter 0 if you have not stopped using tobacco for at least one day.)*

Were you enrolled in a tobacco cessation program this year? *

During the past 30 days, have you had at least 1 drink of an alcohol beverage? *

In the last 30 days, how many days did you have at least one drink of any alcoholic beverage? *
On the day(s) you drank in the last 30 days, about how many drinks did you have? *

Do you have a male parent, sibling, or offspring who was diagnosed with a heart attack, angina, or coronary heart disease at an age younger than 55 years old? *

Do you have a female parent, sibling, or offspring who was diagnosed with a heart attack, angina, or coronary heart disease at an age younger than 55 years old? *

Do you have a male parent, sibling, or offspring who was diagnosed with cancer? *

If so, what type of cancer?

Do you have a female parent, sibling, or offspring who was diagnosed with cancer? *

If so, what type of cancer?

Do you have a grandparent, parent, sibling, or offspring who was diagnosed with diabetes? *

On the average, over the last month, how many days each week did you get at least 30 minutes of exercise?

How many days per week did you exercise or take part in cardiovascular or aerobic activities that made you sweat and breathe hard for at least 30 minutes?

How many days per week did you exercise to strengthen or tone your muscles?

In a typical week, how many days do you take part in any physical activity long enough to work up at sweat.

Please list any vitamins and/or supplements you are taking.

Additional information you would like to convey to us during this visit.

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.

Congratulations, you have registered successfully!

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

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

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

Please review all fields and confirm they are correct.

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27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
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31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

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27	29	30	1	2	3	4	5
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32	3	4	5	6	7	8	9

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27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
30	20	21	22	23	24	25	26
31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

	S	M	T	W	T	F	S
27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
30	20	21	22	23	24	25	26
31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

	S	M	T	W	T	F	S
27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
30	20	21	22	23	24	25	26
31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

	S	M	T	W	T	F	S
27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
30	20	21	22	23	24	25	26
31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

	S	M	T	W	T	F	S
27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
30	20	21	22	23	24	25	26
31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

	S	M	T	W	T	F	S
27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
30	20	21	22	23	24	25	26
31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9

	S	M	T	W	T	F	S
27	29	30	1	2	3	4	5
28	6	7	8	9	10	11	12
29	13	14	15	16	17	18	19
30	20	21	22	23	24	25	26
31	27	28	29	30	31	1	2
32	3	4	5	6	7	8	9