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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 med ical examiner. If the same examiner conducts b oth heart and lung examinations in any one year, only one History form need s to be completed. Name (Last, First, Middle) Age Date of Birth Address Organization/Employer Personal Physician’s Name Occupation IF THE ANSW ER TO ANY QUESTION ON THIS FORM IS “YES”, PLEASE EXPLAIN IN THE SPACE PROVIDED FOR ON THE REVERSE SIDE. YES NO 1. Ha ve you ever had any trouble with your heart or been told that you had trouble with your heart ? 2. Have you ever been treated for high blood pressure or ever been told that your blood pressure was not normal? 3. In the past five years, have yo u been hospitalized overnight for any reason? 4. In the past twelve (12) months, have you seen a doctor for anything other than routine checkups? 5. 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. Do you smoke? If you answer yes, indicate how much per day. Number of packs, cigars, pipefuls, etc. 7. Have you experienced any prolonged shortness of breath? 8. Do you have regular episodes of coughing? 9. Do you drink alcoholic beverages? If yes, indicate daily quantity. Indicate beverage and quantity 10. How many cups of coffee do you usually drink per day? Quantity 11. Do you consider yourself overweight? THE ANSWERS TO THE QUESTIONS ASKED ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE. Signature Date Form OD -1 (rev. 06/14)