Dfs-K4-1022 - Florida Department Of Financial Services printable pdf download

Dfs-K4-1022 - Florida Department Of Financial Services

EPARTMENT OF

INANCIAL

ERVICES

Division of the State Fire Marshal

MEDICAL EXAMINATION TO DETERMINE FITNESS FOR FIREFIGHTER TRAINING

BUREAU OF FIRE STANDARDS AND TRAINING

Please print legibly.

NAME: LAST

FIRST

STUDENT ID

TRAINING

E-MAIL ADDRESS

CONTACT PHONE NUMBER

CENTER

For the medical professional conducting the examination: The purpose of this examination is to

ensure that the physical, physiological, intellectual, and psychological health of the applicant is

suitable for the environment and functions of a firefighter as described on page 2. Authority for this

examination is FS 633.34 and is required before an individual starts firefighter training.

This medical examination must be completed by a physician, surgeon, or physician’s assistant per ch. 458;

or an osteopathic physician, surgeon, or physician’s assistant per ch.459; or an advanced registered nurse

practitioner per ch. 464.

Examination should include but is not limited to:

Dermatological system, Cardiovascular system

Ears, eyes, nose, mouth, throat

Auditory hearing in the pure tone

Clinical evaluation of 12 lead EKG

Far visual acuity corrected or uncorrected

Systolic and Diastolic Blood pressure

Peripheral vision

Respiratory system

Genitourinary system

Gastrointestinal system

Musculoskeletal system

Endocrine and metabolic systems

Neurological system

For the medical professional conducting the examination to complete: (Sign in appropriate box)

Based on the results of this medical evaluation, the applicant:

Has no pre-existing or current condition, illness,

Has a pre-existing or current condition, illness,

injury or deficiency that presents a safety or

injury or deficiencies. The applicant

medically

health risk in the environment or job functions

fit to engage in firefighter training.

is not

of a firefighter. The applicant

medically

fit for firefigther training.

Signature________________________________

Signature_____________________________

Completion Required (please print)

Name of signature: ___________________________________________Date signed: ______________

Office Telephone number: _________________

Office address: ______________________________________________________

DFS-K4-1022 Original Effective Date 9/07/81, Amended Date 01/01/09

Dfs-K4-1022 - Florida Department Of Financial Services

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