Firefighter Academy: Student Health History

Health History

(This form to be completed by Student)
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Age*
Sex
DOB*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Physician*
Hospital of Choice
Should any condition change during enrollment, it is your responsibility to notify the department. Answer each of the following questions truthfully. Falsification of information will result in dismissal.

HAVE YOU NOW, OR EVER HAD, THE FOLLOWING:
Frequent Headaches/Migraines?*

YesNo
Eye, Ear, Nose, Throat Trouble?*

YesNo
Difficulty in Hearing?*

YesNo
Wear Contacts/Glasses?*

YesNo
Sinus Trouble/Frequent Colds?*

YesNo
Asthma/Difficulty Breathing?*

YesNo
Lung Trouble/Pneumonia?*

YesNo
Chest Pains?*

YesNo
Rheumatic Fever?*

YesNo
Heart Disease/Murmur?*

YesNo
Hepatitis/Jaundice?*

YesNo
Hernia/Rupture?*

YesNo
Excessive Bleeding from Cuts?*

YesNo
Thyroid Disease?*

YesNo
Varicose Veins?*

YesNo
Kidney/Bladder Trouble?*

YesNo
Menstrual Trouble?*

YesNo
Foot Trouble?*

YesNo
Sprained/Strained Back/Ruptured Disc?*

YesNo
Arthritis/Painful/Swollen Joints?*

YesNo
Back Trouble/Injury/Unable to lift 50 lbs?*

YesNo
Epilepsy/Fits/Seizures?*

YesNo
Frequent Dizziness/Fainting?*

YesNo
Nervous Breakdown/Memory Loss?*

YesNo
Eating Disorder/Bulimia/Anorexia?*

YesNo
High/Low Blood Sugar/Diabetes?*

YesNo
Take any Prescribed Medication Regularly?*

YesNo
*Allergies/Reactions to Medications/Drugs?*

YesNo
List All Medications Taken Regularly*
Please Specify Any Drug Allergies
If you have no drug allergies, please type NONE
Do you have any serious illness/injury not listed above, or do you have any present concern pertaining to your health which may interfere with activities of the health care program to which you are applying?*

YesNo
If yes, please explain
In case of emergency, please notify:*
Relationship to Emergency Contact:*
Emergency Contact's Phone Number:*
Please enter a valid phone number.
Emergency Contact's Alt Phone:
Please enter a valid phone number.
I certify that all of the above information is true and correct to the best of my knowledge.
Signature

Clear
Should be Empty: