Firefighters and Police Officers Medical History Form To the Firefighter or Police Officer: Please complete this form prior to your examination and present the completed form to the medical examiner. If the same examiner conducts both heart and lung examinations in any one year, only one History form needs to be completed. Name (Last, First, Middle) Address Personal Physician's Name Age Organization/Employer Occupation Date of Birth IF THE ANSWER TO ANY QUESTION ON THIS FORM IS "YES", PLEASE EXPLAIN IN THE SPACE PROVIDED FOR ON THE REVERSE SIDE. YES NO 1. 2. 3. 4. 5. Have you ever had any trouble with your heart or been told that you had trouble with your heart? Have you ever been treated for high blood pressure or ever been told that your blood pressure was not normal? In the past five years, have you been hospitalized overnight for any reason? In the past twelve (12) months, have you seen a doctor for anything other than routine checkups? Have you, or any of your immediate family (father, mother, sister, and/or brother) ever had any of the following? YES (Indicate who has had the problem) NO Allergies (asthma, hayfever, bronchitis, skin rash, eczema)? Eye trouble (other than corrective lenses)? Blood pressure trouble? High blood pressure? Heart trouble? Heart attack? Diabetes? Stroke? Gout? YES NO 6. 7. 8. 9. Do you smoke? If you answer yes, indicate how much per day. Have you experienced any prolonged shortness of breath? Do you have regular episodes of coughing? Do you drink alcoholic beverages? If yes, indicate daily quantity. Number of packs, cigars, pipefuls, etc. Indicate beverage and quantity Quantity 10. How many cups of coffee do you usually drink per day? 11. Do you consider yourself overweight? THE ANSWERS TO THE QUESTIONS ASKED ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE. Form OD-1 (rev. 06/14) Posted 6/27/14 Signature Date American LegalNet, Inc. www.FormsWorkFlow.com