MEMBER QUESTIONNAIRE
Demographic Information:
Name:_________________________________________________
Street:_________________________________________________
Town, Zip:______________________________________________
Phone:________________________Cell______________________
Date of Birth:____________________________________________
Email:_________________________________________________
Primary Occupation:_____________________________________
Personal Physician:_______________________________________
________________________________
Current Member Responsibilities:
Interior Structural Firefighter?
Yes____ No____
Pump Operator?
Yes____No____
Exterior Hoses and Ladders?
Yes____No____
Driver?
Yes____No____
Traffic Control?
Yes____No____
Administration?
Yes____No____
Rescue?
Yes____No____
EMT/Other Medical Training?
Yes____No____
HAZMAT Team?
Yes____No____
Diving/Water Rescue Team?
Yes____No____
SCBA Certified?
Yes____No____
Other Training or FD Duties?_________________________
Exposure History:
In the past 12 months, how many times have you been
exposed to the following contaminants?
Heavy Smoke:______________________________
Burning Plastics:____________________________
Fuel Spills:_________________________________
Chemical Spills:_____________________________
Blood/Body Fluids:__________________________
Other:_____________________________________
____________________________________
Social History:
Do you smoke? Yes____No____Packs per day?__________
Do you drink alcohol?
Yes_____No_______
Number of alcoholic beverages per week:________________
Do you use other drugs such as Marijuana, Cocaine, Heroin,
Amphetamines?
Yes______No______
Have you ever entered a drug or alcohol treatment program?
Yes______No______
Do you engage in a regular exercise program?
Yes______No______
If so, list activities:__________________________________
______________________________________________________________
Current Medications:________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Have you ever suffered from, been diagnosed with or treated
for:
Disorders of eyes, ears, nose or throat?
Yes____No_____
Dizziness, fainting, seizures, migraines, headaches, strokes,
TIA, brain tumor or aneurysm?
Yes____No_____
Shortness of breath, persistent hoarseness or cough,
bronchitis, pleurisy, asthma, emphysema, TB or other chronic
respiratory disorder?
Yes____No_____
Hypertension, heart disease, including palpitations,
arrhythmia, rheumatic fever, murmurs, chest pains, heart
attack, angina, congestive heart failure of other disorder of
heart of blood vessels?
Yes____No____
Hernia, digestive or liver problems?
Yes____No____
Kidney, bladder, prostate, urinary or reproductive disorders?
Yes____No____
Thyroid, or other hormonal disorder?
Yes____No____
Do you have Diabetes?
Yes____No____
Disorder of back, spine, neck bones, arthritis, gout, muscle or
nerve disease or amputation?
Yes____No____
Cancer, blood disorders, leukemia, congenital disorders,
anemia, AIDS, skin diseases?
Yes____No____
Anxiety, depression or mental illness?
Yes____No____
Do your have a family history (parents or brothers? sisters of
heart attack or sudden death before age 55? Yes____No___
Have you been hospitalized or had surgery? Yes____No____
Have you ever had a military rejection, deferment or
discharge because of health?
Yes____No____
Did you ever make a claim for disability benefits or
workman’s compensation?
Yes____No____
Have you been fasting for the last 8 hours? Yes____No____
For any medical history question answered yes, give
explanation below including dates of treatment,
hospitalization, surgery:______________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
I hereby certify that to the best of my knowledge and
belief, all answers and statements are true and complete
and were correctly recorded before I signed my name
below.
I also certify that I have reviewed the Notice of Privacy
Practices and understand my rights with regards to the
use of my protected health information.
I understand that this examination does not take the place
of an annual examination by my personal physician.
Medical History:
Do you have any allergies?
Yes_______No_________
If so, please
list:____________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Date:_____________
Candidate’s signature:_______________________________
Examiner’s signature:________________________________
Physical Examination
Name:____________________________________
Height in shoes: __________Feet________Inches
Weight (clothed)_____________________Pounds
Blood Pressure:
_________/_________
Heart Rate:____________
Cardiovascular: S1 S2 Regular Rhythm? Norm____Abn___
Head, Eyes, Ears, Nose, Mouth, Pharynx? Norm____Abn___
Skin, Lymph Nodes, Varicose Veins,
Peripheral Arteries?
Norm____Abn___
Nervous System (reflexes, gait, paralysis)?
Norm____Abn____
Lungs?
Norm____Abn____
Abdomen (including scars and hernias)? Norm____Abn____
Genitourinary System?
Norm____Abn____
Endocrine System?
Norm____Abn____
Musculoskeletal System (spine, joints,
Amputations, deformities)?
Norm____Abn____
_________________________________________
_________________________________________
For all members over age 40, have you had a digital rectal
exam and stool guaiac in the past year?
Yes___No___
For all female members, have you had a PAP smear in the
past year?
Yes___No___
For females over 40, have you had a mammography in the
past year?
Yes___No___
For all members over 50, have you had a colonoscopy in the
past 3 to 5 years?
Yes___No___
Based on this evaluation the candidate has the
following medical problems:
1. ___________________________________
2. ___________________________________
3. ___________________________________
4. ___________________________________
5. ___________________________________
Based on this evaluation, the candidate should be
referred for the following further studies:
1. ___________________________________
2. ___________________________________
3. ___________________________________
4. ___________________________________
5. ___________________________________
Pulmonary Function Test:____________________
Candidate________________________________
is medically cleared to participate in all aspects
of firefighting duties including the use of the
Self Contained Breathing Apparatus?
Yes_________No___________
Pending further studies the above named firefighter
is conditionally classified in the following manner:
Audiometry:_______________________________
A.______________________________________
EKG:____________________________________
(Interior Structural Firefighter)
Vision: Right eye_____Left eye____ Both______
_________________________________________
Details of “Yes” answers and supplementary
remarks:__________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
B._____________________________
(Exterior only, No SCBA)
C._____________________________
(Administrative Only)
Special conditions or restrictions:______________
_________________________________________
_________________________________________
Examiner’s Name:__________________________
Examiner’s Signature:_______________________
Date:______________
Physical Examination