CLEAR FORM
NEW JERSEY STATE POLICE
Annual Medical History Form
Trooper to Complete:
DATE:
BADGE #:
/
Last
MI
/
GENDER:
AGE:
Female
Male
UNIT CODE:
DATE OF BIRTH:
/
Years
CURRENT WEIGHT: CURRENT HEIGHT:
/
lbs.
ASSIGNMENT:
HOME PHONE:
(
NAME: First
)
inches
SUPERVISOR:
WORK PHONE:
-
feet
BMI:
(
CELL PHONE:
)
-
ext.:
Did you help in the World Trade Center Rescue, Recovery or Cleanup Efforts?
(
Have you been deployed or have you had any exposures?
)
-
YES
NO
YES
NO
If YES, describe any sinus, lung, digestive problems or any related symptoms you are experiencing:
Are you on any medication or supplements?
YES
NO
If YES please list all, include doses:
Allergies (List):
Inhalants:
Foods:
Medications:
Family Health History
Have there been any changes in your family history this year?
Age
Father
If Living
Health
Age at
Death
If Deceased
Cause
YES
NO
Has Any Blood Relative Ever Had:
Whom
Type
Cancer
Mother
Brother/Sister
1.
2.
High
Cholesterol
Diabetes
3.
4.
Heart Disease
5.
High Blood
Pressure
Husband/Wife
Son/Daughter
1.
2.
3.
4.
5.
S.P. 117 (01/12)
Stroke
Kidney
Disease
Depression/
Suicide
Alcohol Abuse
or Alcoholism
Page 1
Medical History
Trooper to Complete:
Personal Medical History
Immunizations
No Chicken Pox
No Flu
Yes
Yes
Yes
No HepA Completed
No HepB Completed
Yes
No Human Papilloma
Virus (HPV) (Gardasil)
No Pertussis
Yes
Yes
Yes
Yes
No Meningitis
No MMR
No Pneumonia
Yes
Yes
Yes
No Polio
No Tetanus
Yes
No Other
Do you currently have
or have you ever had:
NAME: First
Ears
Blood in Urine
Asbestosis Exposure
Burning on Urination
Asthma/Wheezing
Difficulty Starting/Stopping
Discharge
Chest Pain with Deep Breath
Dripping
Frequent Earache
Chronic Bronchitis
Erectile Dysfunction
Frequent Itching in Ears
Chronic Cough
Kidney/Bladder Stones
Hearing Aid
Hearing Loss
Cough when Lying Down
Nighttime Frequency
Coughing at Night
Sexually Transmitted Disease
Ringing in Ears
Coughing Blood in Last Month
Other
Ruptured Eardrum
Daytime Drowsiness
Other
Early Morning Cough
Abnormal Pap
Night Sweats
Anemia
Bleeding Gums
Pneumonia/Pleurisy
Breast Lumps
Difficulty Swallowing
Pneumothorax/Collapsed Lungs
Heavy Bleeding
Enlarged Glands
Productive Cough
Fractured Nose
Shortness of Breath
Hot Flashes/Sweats
Irregular Cycle
Frequent Sinusitis
Shortness of Breath while
walking fast or up slight incline
Loss of Smell
German Measles
Measles
Other
Mumps
Rheumatic Fever
Heart/Circulation
Whooping Cough
Angina
Other
Ankle/Leg Swelling
Shortness of Breath that
interferes with job
Spine/Extremities
Occupational Exposure
Snoring
Chest Pain on Exertion
Tuberculosis
Prescribed Inhalers
Head Trauma
Chest Pain, Pressure, or
Tightness
Concussion
Heart Attack
Dizzy Spells/Seizures
Heart Disease/Disorder
Fainting
Headaches/Migraine
Heart Failure
Heart Murmur
Neck Injuries
Heart Valve Disorder
Bariatric Surgery
Other
High Blood Pressure
Bloating/Gas/Cramping
Leg Cramp When Walking
Bloody or Painful BM
Night Cough
Change in Bowel Habits
Palpitations/Flutters
Weight Loss
Blurred Vision
Persistent Fatigue
Food Intolerance
Change in Vision
Radiating Chest Pain to
Arms, Jaw, Neck, Back
Heartburn/Indigestion
Double Vision
Eye Pain
Eye Surgery/Lasik
Flashes of Light
Glasses/Contacts
Shortness of Breath on Lying
Down
Other
Spotting
Vaginal Discharge
Other
Amputation
Backache/Injury
Difficulty Bending at the knees
Difficulty Climbing a flight of
stairs or ladder carrying more
than 25 lbs
Difficulty Fully Moving Your
Head Up/Down
Difficulty Fully Moving Your
Head Side to Side
Gastrointestinal
Abdominal Pain after Meals
Hemorrhoids
Hiatal Hernia
History of Polyps
Varicose Veins
Nausea/Vomiting
Rigid/Irregular Pulse
Change in Size of Stool
Other
Persistent Diarrhea
Partial Loss of Sight
Reflux
Other
Other
Last Eye Exam:
Severe Cramping
1st Day Last Period
Arrhythmia
Shortness of Breath
Pregnancy Complication
Shortness of Breath while
walking with others at ordinary
pace on level ground
Shortness of Breath while
washing/dressing
Stopping for Breath while
walking at your own pace on
level ground
Color Deficiency
Menstrual History
Emphysema
Nose/Throat
Persistent Hoarseness
Eyes
Urinary
Abnormal Chest X-ray
Chicken Pox
Head/Neck
BADGE #
Difficulty Clearing
Sinuses/Ears
Nose Bleeds
Scarlet Fever/Scarlatina
Lungs
MI
Decrease in Hearing
Frequent Sore Throats
Illnesses
Last
Difficulty Squatting to Ground
Dislocation
Fractures
Joint Pain
Joint Swelling/redness/heat
Sprain/Strains
Weakness of Hands/Feet
Numbness/tingling of
Extremities
Other
Have you had injuries to the following:
Ankle
Elbow
Foot
Hand
Knee
Ligament
Neck
Shoulder
Tendon
Other
S.P. 117 (01/12)
Page 2
Medical History
NAME: First
Last
MI
BADGE #
Trooper to Complete:
Do you currently have or have you ever had:
Thyroid
Substances
Brittle Nails/Hair
Smoke Cigarettes
Decease/Increase in Appetite
Packs per day
Goiter
Smoke Cigars
Hand Tremor
Number per day
Heat/Cold Intolerance
Chew Tobacco
Rapid/Slow Heartbeat
Amount per day
Thyroid Nodule
Drug dependency
Weight Gain
Treatment for Alcoholism
Weight Loss
Other
Surgeries (Type and Date)
Other
HCX CAD
Aspirin
Respirators
Other anti-platelet meds
(Plavix/Ticlid/Coumadin)
Have you ever had Claustrophobia?
YES
NO
Beta Blockers
Have you ever used a respirator?
YES
NO
(Teprol, Coreg, etc.)
If "Yes", list type(s):
Ace Inhibitor
Stent
CABG
If you have used a respirator, did you ever have any of the following
problems?
Angioplasty
HX Diabetes
Eye irritation
Anxiety
Skin allergies or rashes
General weakness or fatigue
Any other problem that interferes with use of a respirator?
HgbA1c Last
Statins use
Check the type of respirator you will use: (Check ALL that apply.)
FBS last
N, R, or P disposable respirator (filter-mask, non-cartridge type only)
Aspirin
Studies
(Provide Dates if Applicable)
Other Type (for example, half or full-face piece type, powered-air
purifying, supplied-air, self-contained breathing apparatus)
CAT Scan
Cardiac Catheterization
Will you be using any of the following items with your respirator(s)?
Chemotherapy
(Check ALL that apply.)
Chest X-ray
HEPA Filters
Coronary CTA
Canisters (ex., gas masks)
Cartridges
EKG
How often are you expected to use the respirator(s)?
MRI
Mammogram
Escape only (no rescue)
Less than 2 hours per day
PAP
Emergency rescue only
2 to 4 hours per day
PSA
Less than 5 hours per week
Over 4 hours per day
Radiation Therapy
Stress Test
During the period you are using the respirator(s), is your work effort
Ultrasound
expected to be heavy (above 350 kcal per hour)?
YES
NO
Other
Will you be wearing protective clothing and/or equipment (other than
Have you been told to have any procedures that you have not had
done?
YES
NO
the respirator) when you will be using the respirator?
YES
NO
If yes, list below:
Will you be working under humid conditions?
YES
NO
Has your employer told you how to contact the health care professional
who will review this questionnaire?
S.P. 117 (01/12)
YES
NO
Page 3
Medical History
NAME: First
Last
MI
BADGE #
Trooper to Complete:
Health Screening
Do you sometimes drink beer, wine, or other alcoholic beverages?
Yes
Spent less time on activities that are usually important or
pleasurable to you?
No
Do people notice that you snore loudly or frequently?
How many times in the past year have you had:
Do you experience gasping or choking spells at night?
(Men) 5 or more drinks in a day?
(Women) 4 or more drinks in a day?
On average, how many days a week do you have an alcoholic drink?
Do people notice that you stop breathing while sleeping?
On a typical drinking day, how many drinks do you have?
Do you have trouble with sleepiness while driving?
In the past 12 months has your drinking repeatedly caused or contributed to:
Do you have trouble with sleepiness during the daytime?
During the past month
Have you often been bothered by feeling down, depressed or
Risk of bodily harm (eg., while operating machinery, swimming, etc.)
Relationship trouble (family or friends)
hopeless?
Yes
No
Have you often been bothered by little interest or pleasure in
Role failure (eg., interference with home, work, parental or marital
doing things?
Yes
No
relationships)
Trouble with administrative, financial or legal issues
In your life, have you ever had any experience that was so
frightening, horrible, or upsetting that in the past month you:
Have had nightmares about it or thought about it when you
In the past 12 months have you:
Not been able to limit your drinking when you tried to?
did not want to?
Not been able to cut down or stop?
Tried hard not to think about it or went out of your way to avoid
Needed to drink a lot more to get the same effect?
situations that reminded you of it?
Experienced tremors, nausea, sweating or insomnia when trying to quit
Were constantly on guard, watchful, or easily startled?
Yes
or cut down?
Yes
No
Yes
No
No
Kept drinking despite problems - physical or psychological?
Felt numb or detached from others, activities, or your
Spent a lot of time planning your drinking or recovering from drinking?
surroundings?
Yes
Physician to Complete:
Examination
No
Findings/Comments
BLOOD PRESSURE:
If Systolic >140, serial pressures to be taken
Ht.
Wt.
HEAD:
Symmetry or deformity
NECK:
Nodes:
EYES:
Pupils round, regular, react to light and accommodations
Vision:
Corrected
OD
OS
OU
Uncorrected
OD
OS
OU
EARS:
Otoscopic visualization of eardrums
NOSE:
THROAT:
Thyroid
S.P. 117 (01/12)
Page 4
Examination
NAME: First
Last
MI
BADGE #
Physician to Complete:
Findings/Comments
Examination
CHEST:
HEART:
CIRCULATION:
Pulses
SKIN:
Melanoma
MUSCULOSKELETAL:
ABDOMEN:
NEUROLOGICAL:
RECTAL:
GENITALIA:
PAP:
Comments/Review of Medical History Form
S.P. 117 (01/12)
Date
Signature of Trooper
Badge No.
Date
Signature of Examining Physician
Physician's I.D. No.
Page 5