Occupational Medicine Firefighter Baseline Evaluation

Name: / Date of Birth: / Today’s Date:
Do you need a DOT Exam? (Circle One) / YES / NO

OCCUPATIONAL HISTORY

Current and Past Work. Please fill in past jobs since high school, starting with your current job and working backwards in time. Include second jobs and military duty. Go back as far as you can.

Employer / Start & End Dates (year) / Job duties / List any potentially hazardous exposures you may have had (metals, chemicals, dust, fumes, temperature extremes, etc.) / Health issues you had during that time period
(current job/ job about to begin) / (in detail for current job)

□ Continued on back of sheet (please check box if additional employers)

Have you had any unprotected exposures to hazardous substances during your current or past work or health concerns related to work activities? □ Yes □ No
If ‘yes’, please explain and list substances, if known:
Have you had any difficulty using personal protective equipment (e.g., SCBA, other respirator, Tyvek suit)? □ Yes □ No
If ‘yes’, please explain:
Have you had any difficulty or do you anticipate any difficulty performing your job, participating in firefighting training simulation, or other job-related training exercises? □ Yes □ No
If ‘yes’, please explain:

MEDICAL HISTORY

Please list or describe your current or significant past medical problems, such as asthma, high blood pressure, fainting, heart problems, or diabetes.
List any past surgeries:
List all medications you currently take (including prescriptions, over the counter medications, and herbal products) and how long you have been taking them:
List all medication allergies:
List any other allergies or sensitivities:

SOCIAL HISTORY

Yes / No / If Yes, please provide additional information.
Do you exercise? / Type of exercise, number of days per week, duration 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? / Greatest number was: ______(packs, cigars, tins, other) per day
Smoked for ______years. Quit date:
Do you have hobbies or activities in your home that could expose you to hazardous dust, smoke, metal fumes, chemical vapors, or loud noise? / Potential home exposures:
What medical problems are common in your family (parents, grandparents, siblings, aunts, uncles, children)? Any heart attacks, heart problems, diabetes, or cancers in your family? / Family member, name of illness, age when illness developed:

Do you have or have you ever had any of the following conditions or symptoms?

Yes / No / Yes / No
6.3 Head and Neck / Chronic bronchitis
Skull, head or face injury / Emphysema
Thoracic outlet syndrome / Pneumonia
Neck cysts or draining wounds / Tuberculosis
Limited movement of the neck / Silicosis
6.4 Eyes and Vision / Pneumothorax (collapsed lung)
Glasses or contact lenses / Lung cancer
Hard contact lenses / Broken ribs
Trouble seeing colors / Chest injuries or surgeries
Retina or optic nerves problems / Cystic fibrosis
Surgeries, including lasik or other vision correction surgery / Asthma
Loss of vision in either eye / Shortness of breath
6.5 Ears and Hearing / Shortness of breath when walking fast on level ground or walking up a slight hill or incline
Balance problems or dizziness / Shortness of breath when walking with other people at an ordinary pace on level ground
Hearing loss or need for a hearing aid / Needing to stop for breath when walking at your own pace on level ground
Ears or ear canal injury / Shortness of breath when washing or dressing yourself
Tumors of the ears or ear canals / Shortness of breath that interferes with your job
Ear infections / Coughing that produces phlegm (thick sputum)
Surgeries on the ear or ear canal / Coughing that wakes you early in am
Ringing in the ears / Coughing that occurs mostly when you are lying down
Rupture of the ear drum / Coughing up blood in the last month
6.6 Dental / Wheezing
Jaw, teeth or gum problems / Wheezing that interferes with your job
Braces or orthodontic appliances / Chest pain when you breathe deeply
6.7 Nose, Oropharynx, Trachea,
Esophagus, and Larynx / Other symptoms that may be related to lung problems
Nose, mouth, or neck trauma / 6.9 Heart and Vascular System
Voice or speech difficulty / Heart attack
Nasal allergies or drainage / Stroke
Nose bleeds / Angina (chest pain)
Sinus infections or headaches / Heart failure
Trouble smelling odors / Swelling in legs/feet (not from walking)
Nose or airway polyps or masses / Heart arrhythmia (heart beating irregularly)
6.8 Lungs and Chest Wall / High blood pressure
Asbestosis / Heart surgeries
Sleep apnea / Defibrillator or pacemaker
Yes / No / Yes / No
Infections of the heart or surrounding tissue / 6.11 Reproductive System
Enlarged heart / Females:
Other heart problem / Are you currently pregnant
Blood clots / Severe pain with menstrual cycles
Abdominal or thoracic aneurysm / Endometriosis or ovarian cysts
Thrombophlebitis or varicose veins / Males:
Raynaud’s phenomenon or other vasospastic disorders / Lumps or masses in or near the testicles
Surgery on any blood vessel / Chronic pain in the testicles, groin or scrotum
Narrowing of the carotid arteries / 6.12 Urinary System
Other blood vessel problems / Kidney failure
Chest pain or tightness / Kidney or bladder disease
Chest pain or tightness during physical activity / 6.13 Spine and Axial Skeleton
Chest pain or tightness that interferes with your job / Back injury
Heart skipping or missing a beat / Back pain lasting more than 1 week
Heartburn or indigestion that is not related to eating / Weakness in arms, hands, legs, or feet
Pain, burning, or numbness in legs with activity & goes away with rest / Limited motion in arms or legs
Swelling of any body part / Pain or stiffness leaning forward or backward at the waist
Feeling dizzy or lightheaded with standing up / Difficulty fully moving your head up or down
Other symptoms related to heart or circulation problems / Difficulty fully moving your head side to side
Wolff-Parkinson-White (WPW)
6.10 Abdominal Organs and Gastrointestinal System / Knee bending difficulty
Inguinal umbilical or femoral hernia / Squatting difficulty
Gallbladder problems / Surgery on back, spine, or neck
Bleeding of the GI tract / Scoliosis or deformities of the spine
Hepatitis / Problems climbing a flight of stairs or a ladder carrying >25 lbs
Inflammatory bowel disease / Other muscle or skeletal problems
Irritable bowel syndrome / 6.14 Extremities
Intestinal obstruction / Hardware such as metal plates or rods supporting a bone fracture
Pancreatitis or pancreas problem / Artificial joint such as hip or knee
Diverticulitis / Missing fingers or limbs
Abdominal or GI surgery / Healing bone grafts
Ulcers / Limited mobility in either shoulder
Cirrhosis of the liver / Dislocated shoulders or shoulder surgery
Spleen problems or removal / Limited mobility in any limb or joint
Repetitive vomiting / Knee surgery or repair
Arthritis
Yes / No / Yes / No
Fractured bone that did not properly heal / Enlarged spleen
Osteomyelitis (bone infection) / Low white blood cell count
6.15 Neurological Disorders / Blood clots or need for blood thinners
Seizures (fits) or Epilepsy / Too many blood cells (polycythemia)
Balance, walking or movement problems / 6.18 Endocrine and Metabolic
Passing out while at rest or with activity / Diabetes
Tremors / Thyroid problems
Muscular weakness / Disease of the pituitary, adrenal, or parathyroid glands
Paralysis of any limb / Other hormone or nutrition problem
Memory problems / 6.19 Systemic Diseases and Miscellaneous
Migraine or other chronic headaches / Lupus, scleroderma, rheumatoid arthritis, or dermatomyositis
Altered sensation or numbness / Burn injury with ongoing problems
Cerebral aneurysm / Heat stress or other heat injury
Multiple sclerosis / 6.20 Tumors and Malignancies
Muscular dystrophy / Tumor, malignancy, or cancer
Head injury / 6.21 Psychiatric Conditions
Bleeding in head or brain / Depression or other mood disorders
6.16 Skin / Anxiety
Skin cancer / Alcoholism
Rashes / Other substance abuse
Skin grafts / Other psychiatric condition
Other skin problem / 6.22 Chemicals, Drugs, and Medications
6.17 Blood / Pain medications
Blood transfusions / Sleep medications
Sickle cell disease / Steroids
Clotting or bleeding disorders / Blood thinners
Anemia (low red blood cell count) / Beta blockers or clonidine
Yes / No
Have you worn a respirator?
If you've used a respirator, have you ever had any of the following problems while using a respirator?
a. Eye irritation
b. Skin allergies or rashes
c. Anxiety
d. General weakness or fatigue
e. Trouble breathing
f. Any other problem that interferes with your use of a respirator
What type of respirator will you use?
a. Disposable respirator (filter-mask, non- cartridge type only).
b. Other type (for example, half- or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus (SCBA)).
Describe the work you will be doing while you are using your respirator(s), including any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases):

Epworth Sleepiness Scale

7.7.21

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?

This refers to your usual way of life in recent times.

Even if you haven’t done some of these things recently try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

It is important that you answer each question as best you can.

Situation / Change of Dozing (0-3)
Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. a theatre or a meeting).
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic
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

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Updated 1.2018