Mine Rescue Team Member Physicians Examination Form printable pdf download

Mine Rescue Team Member Physicians Examination Form

Mine Rescue Team Member

Physicians Examination Form

(To be used in determining the physical condition of a person to wear oxygen breathing apparatus)

22A-1-35 Mine Rescue Teams.

(h) An applicant for initial mine rescue training shall pass, on at least as annual basis, a physical

examination by a licensed physician certifying his or her fitness to perform mine rescue work. A record that such

examination was taken, together with pertinent data relating thereto, shall be kept on file by the operator and a

copy shall be furnished to the director.

In order that wearers of self-contained oxygen breathing apparatus may have their safety assured and

that they may work efficiently, they should be examined by a physician. They should be sound in body, normal in

mind, and physically fit. The following information is the minimum that should be obtained by such an

examination.

Name: __________________________

Address: __________________________

_________________________

Company:________________________

Address:_________________________

_________________________

General Questions

Yes

(Must be answered by the patient)

Have you ever passed out or nearly passed out during or after work or exercise?

Have you ever had discomfort, pain, tightness, or pressure in your chest during work

or exercise?

Does your heart ever race or skip beats (irregular beats) during work or exercise?

Has a doctor ever told you that you have any heart problems? If so, check all that

apply:

□ High blood pressure

□ A heart murmur

□ High cholesterol

□ A heart infection

□ Other: ____________________________

Has a doctor ever ordered a test for your heart? (For example, ECG/EKG,

echocardiogram)

Do you get lightheaded or feel more short of breath than expected during work or

exercise?

Do you cough, wheeze, or have difficulty breathing during or after work or exercise?

Have you ever been treated for diabetes?

Do you have a history of seizure disorder?

Do you wear glasses or contact lenses?

Is there any reason that you could not perform the duties of being on the mine rescue

team? (If yes, explain) _________________________________________________

Mine Rescue Team Member Physicians Examination Form