Volunteer Firefighter
Model Medical Exam and Physical
Attached are samples of a medical questionnaire, medical exam and lab tests that volunteer departments
may adopt for use as a basic physical for firefighters.
These samples are based on NFPA 1582, procedures from other states, and procedures currently used by
cities in Iowa. Departments may modify the samples to meet their particular circumstances or upon
recommendations of the department’s medical director or consulting doctor.
The goal of the physical is to identify if potential firefighters or if existing members of a department have a
medical condition that would limit their functions on the emergency scene. While some conditions may
disqualify a person from being an active firefighter, like a heart disorder, other conditions may simply
require a member to abstain from certain activities on an emergency scene. Providing the physician with a
list of the essential job duties will also help the physician make a sound determination of the member’s
ability to perform the required tasks of a firefighter.
As with all medical information, departments should develop and implement a secured record retention
policy for the medical files, including the examination and physical results.
IWMCA recommends that departments re-examine volunteer firefighters every five years. If a person
experiences a significant health change due to a severe illness or accident, the re-examination may need to
be done sooner upon the advice of a physician.
VFF Model Medical Exam & Physical |Rev: 1.2011 |Iowa Municipalities Workers’ Compensation Association | 1
Name of Examinee ________________________________ Social Security Number _________________________
Medical History (Completed by Examinee before examination)
INSTRUCTIONS: Please answer all questions accurately and completely. If you do not understand any question, you should request clarification from
the examining physician. The information provided regarding your medical history and health habits will be used to make a medical assessment of
whether you can safely and efficiently perform the essential functions of a public safety position. Detailed medical information will be treated
confidentially. It is essential that you answer all questions accurately and completely. Please note that a history of a health problem will be carefully
evaluated and will not necessarily disqualify you from employment.
Do you now have or have you ever had any of the following: (Circle Yes or No)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
Fracture of skull, jaw or facial bones
Concussion or other injury to head Y
Thoracic outlet syndrome
Fracture of neck, vertebrae or spine
Recurrent back or neck pain
Degenerated or herniated disc
Y
Back injury or other abnormality Y
Back, spine or neck surgery
Osteoporosis
Y
Arthritis or joint injury or disease Y
Amputation involving hand or foot Y
Carpal tunnel syndrome
Y
Other hand or wrist problems
Y
Dislocation of any joint
Y
Injury or abnormality of arms or legs
Need for corrective lenses
Deficiency of color vision
Disease of the eyes or sinuses Y
Loss of hearing
Exposure to loud noise
Y
Disease of the ear or vertigo
Deformity of mouth or jaw
Speech impediment or disorder Y
Tuberculosis
Y
Pnemothorax or collapsed lung Y
Bronchitis, asthma or other lung disease
Abnormal electrocardiogram (EKG)
Heart disease or cardiac abnormality
Irregular heart rhythm
Y
Angina/chest pain/shortness of breath
Hypertension/high blood pressure Y
Kidney or Bladder disease
Organ transplant
Liver, pancreas or gall bladder disease
Ulcer or bowel disease
Y
Intestinal bleeding
Y
Hernia of any type
Y
Y
N
Y
Y
Y
N
N
Y
N
N
N
N
N
N
Y
Y
Y
N
Y
N
Y
Y
N
N
N
Y
Y
Y
N
Y
N
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Please explain “yes” answers by referencing item number. Provide (in
the section to the right of each #) pertinent information relative to
diagnosis and treatment for each “yes” response. Include dates for
injuries, illnesses and follow up treatments. Please use the back of this
page if necessary.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
Abnormal balance or coordination
Fainting, blackouts or dizzy spells
Stroke, aneurysm or bleeding in head Y
Multiple sclerosis or muscular dystrophy
Myesthenia gravis or ALS
Y
Epilepsy or seizures
Dementia or memory loss
Y
Migraines or other severe headaches Y
Paralysis or muscle weakness
Other neurological disorders
Y
Eczema or other skin disease
Skin grafts
Bleeding disorder/anticoagulation treatment
Sickle cell disease or trait
Y
Blood clots or thrombosis
Y
High or low blood cell counts
Y
Enlarges or ruptured spleen
Y
Diabetes or high blood sugar
Y
Thyroid or other endocrine disorder Y
Cancer, malignancy or tumor
Y
Mental or emotional disorder
Y
Mental health treatment of any type Y
Lupus, scleroderma, dermatomyositis Y
Heat stroke, frostbite or burns
AIDS, HIV infections or hepatitis
Any history of alcohol or drug abuse Y
Current use of any prescribed drug
Allergies or chemical sensitivities
Occupational (work) injuries
Y
Disability or compensation claim
Asbestos or toxic chemical exposures Y
Required light or restricted duty
Military rejection or medical discharge Y
Medical treatment in past 12 months Y
CAT Scan, MRI or other special tests Y
Smoked cigarettes or tobacco products
Are you pregnant?
Y
Other health conditions requiring treatment
Y
Y
N
Y
N
Y
N
N
Y
N
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
Y
Y
N
Y
Y
N
Y
N
Y
N
N
N
Y
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
VFF Model Medical Exam & Physical |Rev: 1.2011 |Iowa Municipalities Workers’ Compensation Association | 2
Name of Examinee _________________________________ Social Security Number _______________________
Medical Examination
INSRUCTIONS: After reviewing the medical history, conduct a comprehensive examination of all systems
necessary to determine the examinee’s fitness. The examination should include, but not be limited to, the
areas listed below. If the examinee has conditions relevant to a fitness determination which are not listed
below, the examiner is responsible for documenting all such conditions.
Height ____
Weight ____
Blood Pressure ____/___
Temperature ____ Pulse___
Distant
Near
Without Corrective Lenses
Rt. 20/__ Lt. 20/__ Both 20/__
Rt. 20/__ Lt. 20/__ Both 20/__
With Corrective Lenses
Rt. 20/__ Lt. 20/__ Both 20/__
Rt. 20/__ Lt. 20/__ Both 20/__
Vision Testing
Visual Fields
Right: ___ degrees Left: ___ degrees
Color Vision
Ishihara: ___ Normal ___Abnormal
Depth Perception _______
Yarn or Lantern test:
___ Passed ___Failed
EXAMINATION
Normal
Abnormal (Identify by number and explain if abnormal)
1. Skin
______
2. Head, face and scalp
______
3. Ears, tympanic membranes
4. Eyes, pupils, fundi, motion ______
5. Nose, sinuses, olfaction ______
6. Mouth, throat, speech
______
7. Neck, thyroid
______
8. Heart
______
9. Varicosities, bruits, pulses ______
10. Chest, lungs
______
11. Breasts (if indicated)
______
12. Abdomen, hernia
13. Rectum (if indicated)
______
14. Endocrine
______
15. Spinal mobility, alignment ______
16. Upper extremities, hands ______
17. Lower extremities, feet ______
18. Muscle strength, tone
______
19. Gait, Rhomberg
______
20. Balance, coordination
______
21. Reflexes
______
22. Cranial Nerves
______
23. Mental Status
______
___________________________________________________
___________________________________________________
______ ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
______ ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Signature of examining
health care provider ____________________________________________Date __________
Print name of examining
health care provider ___________________________________________ Date ___________
VFF Model Medical Exam & Physical |Rev: 1.2011 |Iowa Municipalities Workers’ Compensation Association | 3
Name of Examinee ________________________________ Social Security Number _________________________
Laboratory/Diagnostic Tests
INSTRUCTIONS: The following tests are required.
TESTS:
A.
B.
RESULTS:
Hearing
Pulmonary Function Test (If wearing SCBA)
___ Normal
___ Abnormal
___ Normal
___ Abnormal
The following tests are also required unless the examining physician determines that they are not warranted.
C.
D.
E.
CBC
___ Normal
___ Abnormal
Chest X-Ray
___ Normal
___ Abnormal
Resting ECG (Every 10 years until 50, then every 2 years) ___ Normal
___ Abnormal
Although not specifically required, additional tests may be performed to further evaluate any conditions detected. For each test
performed indicate below whether the results were normal or abnormal and document any abnormal results. Copies of all
laboratory reports should be attached to this form as part of the permanent record.
VFF Model Medical Exam & Physical |Rev: 1.2011 |Iowa Municipalities Workers’ Compensation Association | 4