APPENDIX 4: DOCTORS MEDICAL ASSESSMENT FORM
Firefighter Health Risk Evaluation – Medical Assessment
(To be completed by the examining doctor)
Firefighter name:_________________________________________________________
DOB:__________________________________________________________________
Rural Fire Authority:______________________________________________________
Date Assessed:__________________________________________________________
Comments on medical history checklist if completed by applicant:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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Examination
General
Height
Weight
BMI
Urinalysis - dip
Cardiovascular
Pulse
Blood Pressure
Heart Apex
Heart sounds
Heart murmurs
Risk Profile
Chest Shape/
Movement
Percussion
Air Entry
Breath Sounds
Peak Flow
Musculoskeletal
Upper limbs/
hands
Shoulders
Neck/Back
Hips
Findings
Comment on Abnormal findings or History
Knees
Ankles
Advance OA
Neurological
Vision Unaided
Aided
Hearing –
Subjective
Ability to
communicate
Balance
Sensory Loss
Tone/Power/
Reflexes
Co-ordination
Right
Right
Left
Left
Examining Doctor’s Comments
_______________________________________________________________________________________________
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Examining Doctor
Name:____________________________________________________
Date:_____________________________________________________ Stamp:
Signature:_________________________________________________