ATTACHMENT_2_Sample_Medical_History_Questionnaire.pdf

DOI Medical Qualification Determination Services

140D0424R0071 Attachment 2 Sample Medical History Page 1 of 7

RFP NO. 140D0424R0071 ATTACHMENT 2: SAMPLE MEDICAL HISTORY QUESTIONNAIRE

TUBERCULOSIS

1. Have you ever had a skin test for TB? ☐Yes ☐No

If yes, when: _____/______/______ (MM/DD/YYYY)

2. Have you ever had a positive TB skin test? ☐Yes ☐No

If yes, did you take INH antibiotic for 3-6 months? ☐Yes ☐No

3. Have you ever been treated for active TB? (TB disease - more than just a positive skin test)? ☐Yes ☐No

4. Have you had symptoms of TB within the last 6 months such as coughing up blood for 2-3 weeks, OR one or more of the following symptoms: chronic cough, chronic fatigue, fever >100, soaking night sweats, unexplained weight loss?

☐Yes ☐No

Please explain ANY YES answers to TB questions – include dates.

Mental Health

1. Have you had any hospitalizations or rehabilitation for mental health issues? ☐Yes ☐No

2. Do you have anxiety, depression, panic disorder, or schizophrenia? (circle the ones that apply) ☐Yes ☐No

If yes, is it: ☐ Current ☐ Ongoing ☐ Resolved more than one year ago

3. Do you have PTSD? ☐Yes ☐No

4. Do you have claustrophobia or fear of heights? (circle the ones that apply) ☐Yes ☐No

5. Do you have any mental health conditions requiring prescription medication? ☐Yes ☐No

Please explain ANY YES answers to mental health questions - include dates.

Vision

1. Do you wear corrective lenses? ☐Yes ☐No

2. Do you wear contacts? ☐Yes ☐No

If yes: ☐ Soft ☐ Hard ☐ Tinted

3. If required, will you carry a duplicate pair of corrective lenses or contact lenses while firefighting? ☐Yes ☐No

4. Have you had any eye surgeries? ☐Yes ☐No

If yes check all that apply: ☐ Strabismus or Lazy Eye ☐ Glaucoma ☐ Retinal Detachment ☐ Lasik ☐ Trauma Please explain ANY YES answers to vision surgeries questions - include dates.

5. Are you color blind or do you have optic neuritis? (circle the ones that apply) ☐Yes ☐No

6. Do you have night blindness, double vision or other visions issues? (circle the ones that apply) ☐Yes ☐No

7. Do you have or have you ever had either partial or complete loss of vision? ☐Yes ☐No

If yes: ☐ Right ☐ Left ☐ Both ☐ Fully recovered and stable OR ☐ Still a problem

8. Do you have difficulty sensing distance or problems with depth perception? ☐Yes ☐No

Please explain ANY YES answers to vision issue questions - include dates.

Ears, Hearing, Nose, Throat

1. Do you have hearing loss? ☐Yes ☐No

2. Do you have vertigo, dizziness, tinnitus (ringing in ears), or Meniere’s disease? (circle all that apply) ☐Yes ☐No

3. Do you have a hearing aid or cochlear implant? ☐Yes ☐No

If yes: ☐ Right ☐ Left ☐ Both

4. Do you have nosebleeds (recurrent or severe - requiring medical care)? ☐Yes ☐No

5. Do you have tumors or polyps? ☐Yes ☐No

6. Do you have allergic rhinitis? ☐Yes ☐No

140D0424R0071 Attachment 2 Sample Medical History Page 2 of 7

7. Have you had ear/nose/throat surgery, other than minor or childhood? ☐Yes ☐No

8. Do you have dental problems, gingivitis, or oral appliances?

Please explain ANY YES answers to any ears, hearing, nose, throat questions – include dates.

Skin

1. Do you have skin cancer? ☐Yes ☐No

If yes: ☐ Basal or Squamous Cell ☐ Resolved ☐ Ongoing treatments ☐ Melanoma (ever)

2. Do you have albinism or other genetic conditions? ☐Yes ☐No

3. Do you have eczema, psoriasis, contact dermatitis or allergic dermatitis? (circle all that apply) ☐Yes ☐No

4. Do you have urticarial, hives or scleroderma? (circle all that apply) ☐Yes ☐No

5. Do you have folliculitis or cystic acne? ☐Yes ☐No

6. Do you have cysts or abscesses requiring surgery? ☐Yes ☐No

Please explain ANY YES answers to skin questions – include dates.

Lungs - Do you have or have you ever had any of the following?

1. Shortness of breath, wheezing or persistent cough (circle all that apply) ☐Yes ☐No

2. Asthma, COPD, emphysema, chronic bronchitis (circle all that apply) ☐Yes ☐No

3. Lung cancer ☐Yes ☐No

4. Sarcoidosis ☐Yes ☐No

5. Pulmonary embolism (clot in lungs) ☐Yes ☐No

6. Collapsed lung ☐Yes ☐No

7. Pulmonary hypertension ☐Yes ☐No

8. Lung Surgery ☐Yes ☐No

9. Loud snoring or pauses in breathing while asleep ☐Yes ☐No

10. Fall asleep easily during the day ☐Yes ☐No

11. Sleep disorder, sleep apnea, narcolepsy or ever advised to use CPAP (circle all that apply) ☐Yes ☐No

If yes, ☐**I have attached a copy of my most recent sleep study and/or CPAP compliance report** Please explain ANY YES answers to lung questions – include dates.

☐** I have attached a copy of my most recent spirometry or PFT, if available. **

Heart – Do you have or have you ever had any of the following?

1. Heart attack or angina ☐Yes ☐No

2. Chest pain or tightness ☐Yes ☐No

3. Congestive heart failure ☐Yes ☐No

4. Cardiomyopathy ☐Yes ☐No

5. Heart block ☐Yes ☐No

6. Pacemaker or ICD ☐Yes ☐No

7. Bypass or valve surgery ☐Yes ☐No

8. Angioplasty or stent ☐Yes ☐No

9. Murmur ☐Yes ☐No

10. Irregular heartbeat, palpitations, or arrthymias (circle all that apply) ☐Yes ☐No

11. Abnormal electrocardiogram (ECG) ☐Yes ☐No

Please explain ANY YES answers to heart questions – include dates.

Hypertension (high blood pressure)

1. Have you ever been diagnosed with hypertension? ☐Yes ☐No

140D0424R0071 Attachment 2 Sample Medical History Page 3 of 7

2. Have you ever had hypertension requiring prescription medication? ☐Yes ☐No

3. Have you ever required hospitalization due to hypertension? ☐Yes ☐No

4. Do you have complications (kidneys, heart, brain, circulation, eyes) (circle all that apply) ☐Yes ☐No

Please explain ANY YES answers to hypertension questions – include dates.

Vascular (clots, circulation) - Do you have or have you ever had any of the following?

1. Peripheral artery disease ☐Yes ☐No

2. Aneurysm ☐Yes ☐No

3. Varicose veins requiring stockings or surgery ☐Yes ☐No

4. Phlebitis, deep vein thrombosis, or clots in legs or lungs (circle all that apply) ☐Yes ☐No

5. Ever been on a blood thinner (Coumadin® or Warfarin, Heparin, Xarelto®) ☐Yes ☐No

6. Raynaud’s ☐Yes ☐No

7. Leg cramps in buttock, thigh, or calf ☐Yes ☐No

8. Vasculitis ☐Yes ☐No

Please Explain ANY YES answers to vascular questions – include dates.

Gastrointestinal (stomach, bowels) – Do you have or have you ever had any of the following?

1. Crohn’s disease, ileitis, ulcerative colitis, other colitis (circle all that apply) ☐Yes ☐No

2. Colostomy or ileostomy (circle all that apply) ☐Yes ☐No

3. Diverticulitis, chronic or recurrent ☐Yes ☐No

4. Irritable bowel syndrome ☐Yes ☐No

5. Cholecystitis (gallbladder), chronic or recurrent ☐Yes ☐No

6. Pancreatitis ☐Yes ☐No

7. Bleeding in the stomach or bowels ☐Yes ☐No

8. Blood in stool or vomited blood ☐Yes ☐No

9. Ulcers ☐Yes ☐No

10. Surgery (gastrointestinal) ☐Yes ☐No

11. Cancer (gastrointestinal) ☐Yes ☐No

12. Any dietary intolerance, special diet, or food allergy? ☐Yes ☐No

Please explain ANY YES answers to gastrointestinal questions – include dates.

Liver

1. Have you ever had hepatitis from any cause? ☐Yes ☐No

2. Do you have cirrhosis? ☐Yes ☐No

3. Have you ever had jaundice (yellow skin) other than infancy? ☐Yes ☐No

Hernias – Do you have or have you ever had any of the following?

1. Inguinal (groin); surgery advised or have had surgery ☐Yes ☐No

2. Abdominal (ventral or umbilical); surgery advised or have had surgery ☐Yes ☐No

3. Femoral; surgery advised or have had surgery ☐Yes ☐No

Urinary (kidney, ureter, or bladder) – Do you have or have you ever had any of the following?

1. Renal (kidney) failure ☐Yes ☐No

2. Dialysis ☐Yes ☐No

3. Difficulty passing urine ☐Yes ☐No

4. Frequent voiding (more than once an hour) ☐Yes ☐No

5. Nocturia or need to void at night ☐Yes ☐No

6. Surgery or missing kidney (circle all that apply) ☐Yes ☐No

140D0424R0071 Attachment 2 Sample Medical History Page 4 of 7

7. Recurrent urine infections ☐Yes ☐No

8. Kidney stones ☐Yes ☐No

9. Nephrotic syndrome ☐Yes ☐No

Please explain ANY YES answers to liver, hernias, or urinary questions – include causes and dates.

Extremities (arms, legs) Do you have or have you ever had any of the following?

1. Amputation or prosthesis ☐Yes ☐No

2. Other orthopedic surgery ☐Yes ☐No

3. Deformity or chronic pain ☐Yes ☐No

Neck or Spine – Do you have or have ever you had any of the following?

1. Neck or spine surgery ☐Yes ☐No

2. Fractures ☐Yes ☐No

3. Chronic back or neck pain or loss of motion ☐Yes ☐No

4. Require assistance from cane, crutches, walker, or wheelchair ☐Yes ☐No

5. Herniated disc ☐Yes ☐No

6. Scoliosis ☐Yes ☐No

Please explain ANY YES answers to neck or spine questions – include dates.

Joints or Arthritis – Do you have or have you ever had any of the following?

1. Any kind of arthritis (rheumatoid, degenerative, gout, etc.) ☐Yes ☐No

2. Joint pain or swelling, loss of motion ☐Yes ☐No

3. Rotator cuff problems (shoulder) ☐Yes ☐No

4. Surgery or joint replacement ☐Yes ☐No

Please explain ANY YES answers to joint or arthritis questions – include dates.

Neurological (brain, nerves) – Do you have or have you ever had any of the following?

1. Seizures or epilepsy ☐Yes ☐No

2. Brain or skull surgery ☐Yes ☐No

3. Concussion or loss of consciousness from hitting head ☐Yes ☐No

If yes, ☐ Over one year ago, fully recovered ☐ Less than one year ago

4. Syncope or fainting ☐Yes ☐No

5. Bleeding in brain ☐Yes ☐No

6. Stroke or TIA ☐Yes ☐No

7. Problem with dizziness, balance or coordination (circle all that apply) ☐Yes ☐No

8. Numbness or tingling in hands or feet ☐Yes ☐No

9. Difficulty sensing hot or cold with hands or feet ☐Yes ☐No

10. Weakness in arms or legs ☐Yes ☐No

11. Peripheral neuropathy from any cause ☐Yes ☐No

12. Multiple sclerosis ☐Yes ☐No

13. Muscular dystrophy ☐Yes ☐No

14. Migraines ☐Yes ☐No

15. Cancer (brain) ☐Yes ☐No

16. Syncope or fainting ☐Yes ☐No

Please explain ANY YES answers to neurological (brain, nerves) questions – include dates.

Endocrine (diabetes, thyroid, etc.) – Do you have or have you ever had any of the following?

140D0424R0071 Attachment 2 Sample Medical History Page 5 of 7

1. Diabetes or elevated blood sugar ☐Yes ☐No

2. Thyroid gland disorder ☐Yes ☐No

3. Adrenal or pituitary gland disorder ☐Yes ☐No

4. Low blood sugar or hypoglycemia ☐Yes ☐No

Please explain ANY YES answers to endocrine questions - include dates.

Hematologic or Blood Immune System – Do you have or have you ever had any of the following?

1. Anemia ☐Yes ☐No

2. Leukemia ☐Yes ☐No

3. Low platelets ☐Yes ☐No

4. Bleeding disorder or coagulopathy, including Hemophilia ☐Yes ☐No

5. Easy bruising ☐Yes ☐No

6. Sickle Cell disease or trait, other hemoglobin variant (circle all that apply) ☐Yes ☐No

7. Enlarged spleen or splenectomy ☐Yes ☐No

8. Immune disorder or infection, including HIV ☐Yes ☐No

9. Myasthenia Gravis ☐Yes ☐No

10. Lupus ☐Yes ☐No

11. Vaccine or immunization intolerance or allergy ☐Yes ☐No

12. Hereditary angioedema ☐Yes ☐No

Please explain ANY YES answers to hematologic questions - include dates.

Females Only Do you have or have you ever had any of the following?

1. Ectopic pregnancy ☐Yes ☐No

2. Severe Menstrual Cramps or Heavy Bleeding ☐Yes ☐No

3. Chronic Pelvic or Abdominal Pain ☐Yes ☐No

4. Surgery ☐Yes ☐No

5. Cancer ☐Yes ☐No

Please explain ANY YES answers – include dates.

Males Only - Do you have:

1. Prostate disease or cancer ☐Yes ☐No

2. Testicular torsion or cancer ☐Yes ☐No

Please explain ANY YES answers – include dates.

Medications

1. Do you currently use an inhaler? ☐Yes ☐No

If yes, check all that apply: ☐ Asthma or COPD ☐ Occasional bronchitis (less than once a year) ☐ Exercise ☐ Allergies

If yes, do you carry it during firefighting? ☐Yes ☐No If yes, please explain:

2. List all current medications and reason for taking.

3. Do you take anabolic steroids or growth hormones? ☐Yes ☐No

140D0424R0071 Attachment 2 Sample Medical History Page 6 of 7

If yes, please explain:

4. Do you take over the counter medications, supplements, or herbal medications? Check all that apply.

☐Yes ☐No

☐Antihistamine or allergy ☐Sedative for sleep ☐Smoking cessation ☐Stimulant ☐Anxiety, etc. ☐Weight loss ☐Other

If yes, please explain:

5. Do you experience any side effects from any medication? ☐Yes ☐No If yes, please explain:

Tobacco Use – if yes check all that apply. ☐Yes ☐No ☐ Cigarettes: Packs per day________ X ________years ☐ eCigarettes: Per day ________ ☐ Cigars: Per day ________ X ________ years ☐ Other tobacco products, chew or snuff Alcohol and Drug Use

1. Do you drink alcohol? ☐Yes ☐No

If yes, please provide the average number of drinks per week ________

2. Have you had or do you have alcoholism, drug or alcohol dependency or abuse? ☐Yes ☐No

3. Do you use illegal drugs, such as marijuana? ☐Yes ☐No

4. Are you currently using someone else’s prescription medication? ☐Yes ☐No

Please explain ANY YES answers to alcohol or drug questions – include dates.

Allergy (medication, bees, other) ☐Yes ☐No Name and reaction:

☐ I have been advised to carry an Epi-Pen.

☐ I have required medical care or hospitalization for an allergic reaction in the past.

Surgery or Hospitalization ☐Yes ☐No If yes, please provide reason and year:

Any health changes since last medical evaluation or exam? ☐Yes ☐No If yes, please explain:

Ever received a permanent disability rating? ☐Yes ☐No If yes, please explain:

Do you have an active workers’ compensation claim related to a work-related injury, illness, or exposure? ☐Yes ☐No If yes, please explain:

Do you have current medical or physical work restrictions? ☐Yes ☐No If yes, please explain:

140D0424R0071 Attachment 2 Sample Medical History Page 7 of 7

I hereby certify that the above answers are complete and accurate to the best of my knowledge.

Examinee Name (Please Print) Signature Date