Firefighters and Police Officers Extensive Heart Examination Form Name (Last, First, Middle) Sex Date of Examination Address Age Date of Birth Personal Physician's Name Occupation PHYSICAL HEIGHT WEIGHT EKG NORMAL ABNORMAL (Specify) BLOOD PRESSURE OVERWEIGHT? YES NO STRESS EKG* NORMAL years *If 40 years old or older or if abnormalities with resting EKG and no contraindications to performing test exist. ABNORMAL (Specify) STETHOSCOPIC EXAMINATION OF THE HEART NORMAL ABNORMAL (Specify) Triglycerides Cholesterol Urine Glucose It is recommended that you contact your personal physician for advice concerning correction of . . . Examiner's Signature Date Please sign one copy of this form and submit it to your employer or organization. Employee's Signature Date Form OD-3 (rev. 06/14) Posted 6/27/14 American LegalNet, Inc. www.FormsWorkFlow.com