Firemen and Police Medical History Form.doc

STATE OF NEVADA

FIREMEN AND POLICE MEDICAL HISTORY FORM

NAME_____________________DOB_________AGE____SEX______

AGENCY DIVISION JOB CLASSIFICATION

If the answer to any of the questions is” Yes”, please explain in the space provided at the end of this questionnaire. Have you or any of your immediate family (father, mother, sisters or brother) ever had any of the following:

RELATIONSHIP

____Yes_____No Allergies (asthma, hay fever, bronchitis, skin rash, eczema

____Yes_____No Eye Trouble (other than corrective vision)

____Yes_____No Blood pressure trouble

____Yes_____No Heart trouble ____Yes_____No Diabetes ____Yes_____No Stroke

____Yes_____No Gout

____Yes_____No Tuberculosis

____Yes_____No Rheumatic Fever

____Yes_____No Cancer

2.___Yes____No Have you ever had trouble with your heart or been told that you had trouble with your heart?

3.___Yes____No Have you ever been told you have an abnormal EKG or irregular heartbeat?

4.___Yes___No Have you ever been treated for high blood pressure or been told that your blood pressure was not normal?

5.___Yes____No In the past five years, have you ever been hospitalized overnight for any reason?

6.___Yes____No In the past twelve months, have you seen a doctor for anything other than routine checkups?

7.___Yes____No In the past twelve months have you sought any psychological therapy or counseling?

8.___Yes____No Have you ever been treated for or told that you have a disease of the lungs?

9.___Yes____No Have you experienced prolonged shortness of breath?

10.___Yes____No Do you have a persistent cough or long episodes of coughing?

11.___Yes___No Have you ever felt the sensation of smothering or inability to breathe?

Name__________________________________ 12.__Yes____No Have you been out of the country in the last three months? Six months? Year?

13.____Yes___No Have you ever experienced heat exhaustion or heat stroke?

14.____Yes___No Have you ever had or been told you had a ruptured eardrum?

15.____Yes___No Do you have or have you ever been told that you have defective hearing?

15.____Yes___No Have you ever had a problem with dizziness, seizures, or fainting spells?

17.____Yes___No Have you ever had a head injury, spinal injury, or surgery?

1.____Yes___No Are you currently taking any prescription medications? If yes , List________________________________________________________________ 18.____Yes___No Do you smoke? If yes, how many cigarettes/cigars per day?

If no, and you are a former smoker, what date did you last smoke ____Yes___No Do you use any “smokeless” tobacco products such as snuff or chew? E-cigarettes?

Nicotine products? Vape?

19.____Yes___No Do any members of your immediate family smoke?

20.____Yes___No Do you drink alcoholic beverages? If yes, how many per day?__Avg. per week?____

21.____Yes___No Do you drink coffee? If yes, how many cups do you usually drink per day?

22.____Yes___No Do you consider yourself overweight?

23.____Yes___No Describe any seasonal or routine sports or physical exercise that you routinely participate in _________________________________________________________

In the area below please describe in detail any “Yes” answers to the above questions beginning with the number of the question.

Question # Detailed information

Name__________________________________

Please use the back of this page should you need additional space.

The answers and information provided to the above questions are true to the best of my knowledge and beliefs.

SIGNATURE________________________________DATE_____________________________

Revised 6-23