Firefighter Medical Exam Template - Lorain County Fire Chiefs Fire Training Program
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1
2Firefighter Medical Exam
(to be completed by licensed physician, physician’s assistant or nurse practitioner)
Name: ____________________________________________________________________________________
Height: ____’______”
Weight: _________ lbs.
Student is able to send verbal messages
yes
no
Vision Status: Right Eye: 20/_____ Left Eye: 20/ _____ Corrected: ___________________________
Blood Pressure: ______/______ Pulse Rate: _______
Normal
Abnormal
If abnormal, explain
1. Skin
_______________________________
2. Head & Neck
_______________________________
3. Eyes
_______________________________
4. Ears, Nose, Throat
_______________________________
5. Teeth & Mouth
_______________________________
6. Lungs & Chest
_______________________________
7. Cardiovascular
_______________________________
8. Abdomen & Lymphatics
_______________________________
9. Genitalia/Hernia
_______________________________
10. Orthopedic Screening:
a. Upper Extremities
_______________________________
b. Lower Extremities
_______________________________
c. Spine & Back
_______________________________
11. Neurological
_______________________________
Tests and/or Vaccinations
a. Tetanus BoosterDate:
_____________
b. Hepatitis: Shot Dates:
1._____________
2._____________
3._____________
Additional comments: ______________________________________________________________________
_________________________________________________________________________________________
Note: The student has provided me a copy of the “essential functions” for the program and he or she should be
able to perform these functions.
This is to certify that on this ________ day of ___________________, _________, I performed the above
limited examination of _______________________________ and based upon the medical history given, and
upon my evaluation, I am of the opinion that he/she IS_____ IS NOT _____ physically and medically able to
participate in the Lorain County Fire Chiefs Fire Training program.
Signature:_____________________________ Date:______________ Phone #:________________
Name: ________________________________________________________________________
Address:_________________________________________________________________________________
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Parent category: Medical