Occupational Medicine Firefighter Periodic Evaluation
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- Matilda Berenice Higgins
- 6 years ago
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1 Name: Date of Birth: Today s Date: Do you need a DOT Exam? (Circle One) YES NO OCCUPATIONAL HISTORY Employer: Year of Hire: What are your current job duties? Check all that apply. Firefighting Office work/administration Medical calls Hazardous materials response Investigation Other Since your last work physical, have you had any unprotected exposures to hazardous substances? (e.g., getting exposed to chemicals without wearing your turnouts or breathing in chemicals without using your respirator) Yes No If yes, please explain and list substances, if known: In the past year, have you had any difficulty using personal protective equipment [e.g., SCBA (selfcontained breathing apparatus), other respirator, Tyvek suit]? Yes No Have you noticed any health problems you think may be related to your job? Yes No Have you had any difficulty doing your job, participating in firefighting training simulation, or other job-related training exercises? Yes No In the next year, do you anticipate any difficulty/ies performing your job, participating in firefighting training simulation, or other job-related training exercises? Yes No Page 1 of 5
2 MEDICAL HISTORY Please list or describe your current medical problems, such as asthma, high blood pressure, high cholesterol, or diabetes. List any surgeries: List all medications you currently take (including prescriptions, over the counter medications, and herbal products): List all medication allergies: SOCIAL HISTORY Do you exercise? Yes No If Yes, please provide additional information. Type of exercise, number of days per week, length of exercise sessions: Do you drink alcohol? How many drinks per week? Do you currently smoke or use smokeless tobacco? (packs, cigars, tins, other) per day Did you previously smoke or use smokeless tobacco? Do you have hobbies or activities in your home that could expose you to hazardous dust, smoke, metal fumes, or chemical vapors (e.g., welding, auto repair, spraypainting)? Family Medical History Mother Father Grandmothers Grandfathers Aunt or Uncle Children Greatest number was: (packs, cigars, tins, other) per day Smoked for years. Quit date: Potential home exposures: Medical Conditions (heart attack, diabetes, cancer, etc.) and age at onset Page 2 of 5
3 Have you experienced any of the following symptoms or conditions since your last work physical? Yes No Yes No 9.4 Cardiovascular Disorders Pneumothorax (collapsed lung) Heart attack Lung cancer Stroke Broken ribs Angina Any chest injuries or surgeries Heart failure Any other lung problem that you've been told about Heart valve problem, e.g. mitral valve Shortness of breath stenosis, aortic stenosis Swelling in your legs or feet (not caused by walking) Heart arrhythmia (heart beating irregularly), e.g. atrial fibrillation High blood pressure Shortness of breath when walking fast on level ground or walking up a slight hill or incline Shortness of breath when doing firefighting simulations or other training exercises Have to stop for breath when walking at your own pace on level ground Shortness of breath when washing or dressing yourself Shortness of breath that interferes with your job Coughing that produces phlegm (thick sputum) Coughing that wakes you early in the morning Coughing that occurs mostly when you are lying down Any other heart problem that you've been told about chest chest during physical activity chest that interferes with your job In the past two years, have you noticed your heart skipping or missing a beat Heartburn or indigestion that is not Coughing up blood in the last month related to eating Any other symptoms that you think Wheezing may be related to heart or circulation problems 9.5 Vascular Disorders Wheezing that interferes with your job Aneurysm, e.g. aortic aneurysm Chest pain when you breathe deeply Blood clots, e.g. deep vein thrombosis Any other symptoms that you think may be related to lung problems Poor circulation to hands or feet Allergic reactions that interfere with your breathing 9.6 Endocrine and Metabolic Disorders 9.8 Infectious Diseases Diabetes mellitus (high blood sugar) Skin infections Thyroid disorder (high or low thyroid) Ear infections Adrenal gland or pituitary disorder Intestinal infections 9.7 Lung, Chest Wall, and Respiratory Urinary or kidney infections Disorders Asbestosis Hepatitis Asthma Other ongoing/persistent infection Chronic bronchitis Emphysema Pneumonia Tuberculosis Silicosis Page 3 of 5
4 Yes No Yes No 9.9, 9.10 Spine and Orthopedic Disorders Difficulty hearing Weakness your arms, hands, legs, or feet Wear a hearing aid Back pain or back injury Any other hearing or ear problem Difficulty fully moving your arms and legs Dizziness, light-headedness or vertigo ( room spinning ) Back pain or stiffness when you lean 9.13 Neurologic Disorders forward or backward at the waist Difficulty fully moving your head up or down Difficulty fully moving your head side to side Difficulty bending at your knees Difficulty squatting or crawling on the ground Problems climbing a flight of stairs or a ladder carrying more than 25 lbs Any other muscle or skeletal problem that interferes with doing your job or using a respirator Amputation Joint replacement or artificial joint Joint dislocation Limited joint motion Arthritis, Osteoarthritis Rheumatoid or inflammatory arthritis 9.11 Disorders of the Gastrointestinal Tract and Abdominal Viscera Gallbladder problems Heartburn or GERD Bleeding from stomach or intestines Ulcers Inflammatory bowel disorder Irritable bowel syndrome Pancreatitis Diverticulitis Spleen removal Cirrhosis Hernia 9.12 Medical Conditions of the Head, Eyes, Ears, Nose, Neck, or Throat Trouble smelling odors Eye irritation Lost vision in either eye (temporarily or permanently) Wear contact lenses Wear glasses Color blind Any other eye or vision problem Injury to your ears, including a broken ear drum Weakness or fatigue Seizures (fits) Balance problems Loss of consciousness (syncope) or near loss of consciousness Tremor Numbness or tingling Weakness of an arm or leg Head injury Concussion Memory problems 9.14 Psychiatric Concerns Claustrophobia (fear of closed-in places) Anxiety Depressed mood Stress Other psychological concerns 9.15 Substance Abuse Alcoholism Other drug abuse 9.16 Medications Do you currently take medication for any of the following problems? a. Breathing or lung problems b. Heart trouble c. Blood pressure d. Seizures (fits) Anticoagulant (e.g. Coumadin) Pain medication Steroids Sleep medication Mental health medication 9.17 Tumors Malignant or Benign Any cancers or tumors Other: Skin rashes or skin allergies Page 4 of 5
5 Please provide information about your yes responses to the medical questions above. The above medical history is accurate to the best of my knowledge. Signature Date Physician Section Comments: I have reviewed and discussed the medical information provided in this questionnaire with this employee. Signature Date and Time Page 5 of 5
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