section 1 applicant to complete - iworkfor.nsw

Applicant Name: ………….......................…………………………

Sensitive: Personal

NSW RFS Medical Assessment – Specialist

Section 1 – Applicant to complete

Section 2 – Applicant and Doctor to complete Section 3 – Doctor to complete Section 4 – Doctor to complete and Applicant

to forward with Application

SECTION 1 – APPLICANT TO COMPLETE

Please write clearly in BLACK pen and BLOCK letters, completing all sections with as much detail as possible. Insufficient information may delay your application.

APPLICANT’S DETAILS

Family Name First Name

Middle Name Date of Birth (DD-MM-YYYY)

- -Male Female

Street Address

Suburb State Postal Code

Daytime Contact Telephone Number (Home / Work)

( )Phone (Mobile)

Email (preferred method of contact – print clearly in capitals)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ @ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ . _ _

Brigade District:

APPLICANT’S REGULAR GENERAL PRACTITIONER DETAILS

Doctor’s Name Doctor’s Telephone Number

Doctor’s Postal Address (Street Number and Name)

Suburb State Postal Code OR I do

not have a regular GP

OCCUPATIONAL HISTORY

Year Job Title or Description

From To

Version 1.0 17/02/2015

Applicant Name: ……........................……………………….....…

NSW RURAL FIRE SERVICE

2 of 14Sensitive: Personal

GENERAL HISTORY

Are you right or left handed? Right Left

Do you smoke?

If YES, how many cigarettes a day?

How many years have you smoked?

Yes No

_________ cigs/day

___________ years

Did you smoke in the past?

If YES, how many years did you smoke?

How many years ago did you stop smoking?

Yes No

___________ years

___________ years

Do you drink alcohol?

Less than or up to10 standard drinks per week

More than 10 standard drinks per week

Yes No

Yes No

Yes No

Do you regularly use non-prescription drugs?

(including illegal and/or recreational drugs) Yes No

If YES, what type and how often?

Do you do any regular exercise? Yes No

If YES, please provide details of what and how often in the space provided below.

Structured exercise (e.g. gym visits, social sports, competitive sports etc.)

Incidental exercise (e.g. housework, work, playing with children etc.)

Has any close blood relative (mother, father, sister, brother) had any of the following: diabetes, heart condition, stroke, cancer, nerve

condition and/or hereditary disease? Yes No

If YES, please give details and age of onset of the condition(s):

Applicant Name: ……........................……………………….....…



SECTION 2 – APPLICANT TO COMPLETE AND DOCTOR TO COMMENT

Applicant - please circle YES or NO to the questions below.

Doctor - if the answer to any question is YES please ensure the applicant has provided details onpage 6 and you have signed these details as correct.

MEDICAL HISTORY DETAILS Doctor to comment on all ‘yes’ responses

Are you being treated by a doctor for any illness? Yes No

Are you taking any prescription medication?

If YES, what type and how often?

……………………………………………………. …………………………………………………….

Are you taking this medication as prescribed?

Yes

Yes

No

No

Have you been hospitalised in the last 12 months? If YES provide details.

Yes No

Have you ever been immunised against:

Hepatitis B full course x 3 vaccinations?

Tetanus?

Yes

Yes

No

No

Dose 1 _ _/_ _/_ _ Dose 2 _ _/_ _/_ _ Dose 3 _ _/_ _/_ _

Dose 4 _ _/_ _/_ _ or booster shot if applicable

Date: _ _/_ _/_ _

1. Respiratory Conditions: Do you have, or have you EVER had?

a. Asthma / wheezing Yes No e. An inhaler (puffer) Yes No

b. Recurrent bronchitis Yes No f. Pneumothorax Yes No

c. Shortness of breath Yes No g. Sleep apnoea Yes No

d. Persistent cough Yes No h. Tuberculosis Yes No

Doctor - Complete the following if there is a history of asthma, asthma like symptoms or inhaler use:

a. Age of onset of asthma or asthma like symptoms: e. Name, dose and frequency of current medication usedfor asthma or asthma like symptoms:

b. When were the last reported symptoms of asthma orasthma like symptoms:

f. List name and date of previous medication used forasthma or asthma like symptoms and date whenceased.

c. Frequency and severity of asthma symptoms orasthma like symptoms:

g. Has oral steroid treatment ever been required? (e.g.prednisone) If yes, why and when?

d. Precipitants for asthma or asthma like symptoms: h. Has hospital treatment ever been required? If yesplease provide approximate dates or years.

Applicant Name: ……........................……………………….....…



2. Cardiovascular Conditions: Do you have, or have you EVER had?

a. Chest pain or discomfort, angina Yes No f. High or low blood pressure Yes No

b. Heart attack or heart failure Yes No g. Heart valve problem Yes No

c. Stroke, mini stroke or transientischemic attack

Yes No h. Peripheral vascular diseases Yes No

d. Heart disease, surgery orcardiovascular procedure e.g.bypass, stent

Yes No i. Deep vein thrombosis, pulmonary

embolism ( clots on the lungs) or blood clotYes No

e. An irregular heart beat or palpitations Yes No j. Any other heart /cardiovascular problems Yes No

3. Neurological Conditions: Do you have, or have you EVER had?

a. Head injury/concussion Yes No d. Severe, frequent migraine or headaches Yes No

b. Epilepsy, convulsions or seizures Yes No e. Any other neurological problem? e.g.

multiple sclerosis, Parkinson’s diseaseYes No

c. Fainting spells, blackouts, dizzinessor funny turns

Yes No

4. Abdominal Conditions: Do you have, or have you EVER had?

a. Any significant bowel disorder Yes No c. Hepatitis Yes No

b. Hernia Yes No d. Any other abdominal problem? Yes No

5. Kidney Conditions: Do you have, or have you EVER had?

a. Kidney disease Yes No d. Dialysis Yes No

b. Impaired kidney function Yes No e. Disease of the urinary tract Yes No

c. Loss of a kidney Yes No f. Any other kidney problem? Yes No

6. Musculoskeletal Conditions: Do you have, or have you EVER had?

a. Any broken bones Yes No ** Location of injury (if limb indicate which side):

b. Neck injuries and/or problems Yes No j. Any other problem affecting general

strength or fitnessYes No

c. Back injuries and /or problems Yes No k. Dislocation or recurrent dislocation of joint Yes No

d. Shoulder injuries and/or problems Yes No l. Surgery to limbs or spine Yes No

e. Elbow injuries and/or problems Yes No m. Any amputation of a hand, foot or limb Yes No

f. Wrist injuries and/or problems Yes No n. Arthritis or joint replacement Yes No

g. Hip injuries and /or problems Yes No o. Any other musculoskeletal problem Yes No

h. Knee injuries and /or problems Yes No p. Do you wear or have you been advised to

wear orthotics?Yes No

i. Ankle injuries and /or problems Yes No q. Do you have foot problems that might affect

your ability to wear boots?Yes No

Applicant Name: ……........................……………………….....…



7. Blood Conditions: Do you have, or have you EVER had?

a. Anaemia Yes No c. Condition causing increased clotting Yes No

b. Condition causing increased

bleeding including blood-thinning

medication

Yes No d. Any other disorder of the blood e.g.

leukaemiaYes No

8. Endocrine Conditions: Do you have or have you EVER had?

a. Thyroid or other gland problem Yes No c. Diabetes or pre-diabetes condition Yes No

b. Osteoporosis/Osteopenia Yes No

9. Hearing Conditions: PLEASE READ AND COMPLETE BEFORE YOU ATTEND FOR THE HEARINGASSESSMENT

Prior to undertaking your audiometry test please ensure you have had a period of 16 hours noise free i.e. not attending assessment after a rock concert, using power tools or listening to loud music in the car or via ear phones.

If you have an increase in ear wax, cold or flu like symptoms, ear ache or an ear infection at the time of your appointment, please reschedule until the symptoms have resolved.

Please complete the questionnaire and submit with your paper work.

I have had a period of at least 16 hours of quiet time (i.e. not attending after a rock concert, using power tools or listening to loud music in the car or via ear phones).

Yes No if no, how many hours have passed since you took part in any of these activities?

Do you or have you ever had?

a. Ringing of the ears/tinnitus Yes No h. Glue ear/grommet surgery Yes No

b. Increased wax in ears Yes No i. Other surgery on ears Yes No

c. Discharge from ears Yes No j. Any periods of dizziness Yes No

d. Sinus infections Yes No k. Measles or mumps infections in

childhoodYes No

e. Exposure to antibiotics in childhood Yes No l. Family history of deafness Yes No

f. Congenital ( from birth) deafness Yes No m. Cochlear implants/ hearing aids Yes No

g. Have you recently been on a longhaul flight

Yes No

OCCUPATIONAL HISTORY PLEASE PROVIDE DETAILS

a. Have you participated in Militaryservice?

Yes No How many years served?

b. Do you currently wear any hearingprotection for work or hobbies

Yes No

Class

Training provided

c. Are you a deep sea diver? Yes No Date of last dive

d. Have you ever been exposed toexplosions or gunfire

Yes No Date of last exposure

Applicant Name: ……........................……………………….....…



e. Have you ever been involved inmotor racing


f. Have you ever been exposed toloud music


10. Visual Health: Do you have, or have you EVER had?

a. Reduced vision - need for contactlenses or spectacles

Yes No c. Uveitis, keratoconus, retinal disease or

any other disease of the eyeYes No

d. Glaucoma or cataracts Yes No d. Colour blindness Yes No

11. Mental Health: Do you have, or have you EVER had?

a. Depression or anxiety Yes No e. Attention deficit disorder (ADD) or

attention deficit hyperactivity disorder(ADHD)

Yes No

b. Psychosis, schizophrenia, bipolardisorder, post traumatic stressdisorder

Yes No f. Problems with working at heights or in

confined spacesYes No

c. Stress or other psychiatric conditionwhich required medical consultation

Yes No g. Adverse reaction to distressing sights

and eventsYes No

d. Substance abuse or alcoholdependence or abuse

Yes No h. Medication for a

psychological/psychiatric/ mental healthcondition?

Yes No

12. Miscellaneous Conditions: Do you have, or have you EVER had?

a. Allergies or anaphylaxis Yes No e. Cancer or malignant tumour of any kind Yes No

b. Skin disorders/dermatitis Yes No f. Chronic fatigue syndrome Yes No

c. Skin cancer Yes No g. Sleep disorders Yes No

d. Facial burns, injuries or fractures (e.g. jaw) that may affect ability to wear breathing apparatus Yes No

13. Females Only

a. Are you currently pregnant? Yes No

APPLICANT

Please forward a copy of medical correspondence for any conditions to which you answered ‘yes’, i.e.

specialist letters, hospital discharge summary, X-ray,

CT scan, MRI reports.

Applicant Name: ……........................……………………….....…



14. General Medical Questionnaire

APPLICANT AND/OR DOCTOR

Please provide details for all ‘yes’ answers in Questions 2 – 12 by answering all applicable questions in

rows A – M. If an answer is not applicable place “N/A” in the column. Please use an additional sheet if required.

Question No. Q.___ Q.___ Q.___ Q.___

a. Date condition firststarted and descriptionof symptoms.

b. What was the conditionand which part of thebody was affected?

c. What was the medicaldiagnosis includingresults of x-rays andinvestigations?

d. What was the frequency(daily, weekly, etc) ofattacks or symptoms?

e. What was the severity(mild/moderate/severe)and duration of attacksor symptoms?

f. How long were youunable to work orperform your normalduties/activities?

g. If a hospital visit wasrequired, please providedate and duration ofyour stay.

h. What advice/treatmentdid you receive?

i. Are you still receivingtreatment? If so, pleaseadvise nature andfrequency of treatment.

j. Date treatment/medication ceased?

k. When did you last sufferfrom any symptoms?

l. Degree of recovery (%)

m. Please provide full nameand address of alldoctors, hospitals orother practitionersconsulted.

DOCTOR Please check the above information has been correctly reported by the applicant, I have checked the above information is

correct.

______________________________________ (Signature of Doctor completing the examination)

Applicant Name: ……........................……………………….....…



APPLICANT

Please state any other medical condition, injury, hospitalisation and/or surgery you have had.

Approximate Date Medical condition, injury, hospitalisation and/or surgery

Additional Medical Notes:

Applicant Name: ……........................……………………….....…



DECLARATION Must be signed - failure to do so may result in your application being delayed

I hereby declare all the information I have provided in this document is true and accurate.

I understand this information will be used by NSW Rural Fire Service for the purposes of assessing my suitability to meet the task demands of certain specialist functions as outlined in the relevant Role Profile.

I understand if the information provided by me is false or misleading, this may result in termination of my application, and/or termination of my employment.

I understand this information will not be used or disclosed for a purpose other than the purpose for which it was collected, without my consent.

I understand this information may be used for statistical analysis and reporting, but only after my identification has been removed.

I understand that I am able to access health information held about me by NSW Rural Fire Service, as per the NSW Health Records and Information Privacy Act 2002, and its successors.

I understand all information obtained by the NSW Rural Fire Service will be used by for the purposes as mentioned in this document.

I hereby authorise and direct any Doctor, hospital or other medical or health service provider to release details of my personal medical history, including referrals to or treatment by any other Practitioners, to NSW Rural Fire Service.

I hereby authorise the NSW Rural Fire Service to forward any relevant health information to my usual general practitioner (I have provided details in my questionnaire) or other assessing health practitioners.

A photocopy of this authorisation shall be as valid as the original.

Applicant Name:

Applicant Signature:

Date:

Applicant Name: ……........................……………………….....…



SECTION 3 – DOCTOR TO COMPLETE

Please print clearly, ensuring all sections are completed. Failure to do so may delay the application.

DOCTOR’S EXAMINATION FINDINGS

Measurements Comment

WEIGHT ___________kg HEIGHT ____________cm

BMI (weight ÷ height in meters ²) = ____________

WAIST GIRTH ___________cm

Vision Both ‘Corrected’ and ‘Uncorrected’ vision assessment is required where applicant uses glasses/contact lenses.

Uncorrected Corrected (if necessary)

Distance Vision

Right Left Both Right Left Both

6/ 6/ 6/ 6/ 6/ 6/

Visual fields (to confrontation) Normal Abnormal Comments:

Colour Vision

(Ishihara) No. of errors: No. of plates used:

Is there any defect or disease of the eyes? No Yes Details:

Does the applicant wear glasses or contact lenses? No Yes Type of correction used:

Ear, Nose, Throat and Face

Is there any defect in hearing or speech? No Yes Details:

Any hearing concerns indicated in hearing health questionnaire No Yes

Is there any facial deformity which may interfere with the fit of a breathing apparatus mask? No Yes

Attached audiogram results? No Yes

If audiogram unavailable, please complete Whisper Test below:

Whisper Test Normal Abnormal

Right Ear

Left Ear

Cardiovascular System Doctor to comment on abnormal results

Blood pressure ..……../…..…. *

2nd

Reading ..……../…..…..

3rd

Reading ..……../…..…..

Normal Abnormal

* Repeat if above 135/85after 5 and 10 minute intervals

Pulse rate = …………….bpm Regular Irregular

Heart sounds Normal Abnormal

Murmurs Absent Present

Evidence of cardiac failure/oedema No Yes

Applicant Name: ……........................……………………….....…



Varicose veins No Yes

Peripheral pulses Present Absent

Is there any evidence of disease of the heart or vascular system generally? No Yes

Respiratory System Doctor to comment on abnormal results

Respiratory rate = …………. Normal Abnormal

Air entry Normal Abnormal

Breath sounds Normal Abnormal

Wheeze No Yes

Spirometry

Please ensure compliance with the spirometry information fact sheet (3 acceptable/reproducible traces).

Spirometry printout attached Yes No

Mental Health

If there is any history of mental illness, please provide information regarding the history and current condition. Please also state any significant triggers as well as current treatment.

Neurological System Doctor to comment on abnormal results

Is there any evidence of neurological disorder?

No Yes

Balance (Romberg’s test) Normal Abnormal

Is there any presence of tremor? No Yes

Locomotor System Doctor to comment on abnormal results

Stance, gait and posture Normal Abnormal

Squatting Normal Abnormal

Squat walk Normal Abnormal

Muscle tone Normal Abnormal

Thoracolumbar spine range of movement Normal Abnormal

Cervical spine range of movement Normal Abnormal

Applicant Name: ……........................……………………….....…



Upper Limbs Doctor to comment on abnormal results

Power and coordination Normal Abnormal

Reflexes Normal Abnormal

Hands - fine motor, grip strength Normal Abnormal

Shoulder - range of movement Normal Abnormal

Shoulder - supraspinatus impingement No Yes

Lower Limbs Doctor to comment on abnormal results

Power and coordination Normal Abnormal

Reflexes Normal Abnormal

Straight leg raise Normal Abnormal

Knee Examination Left Right Doctor to comment on abnormal results

Swelling or deformity No Yes No Yes

Joint tenderness No Yes No Yes

Normal range of movement Yes No Yes No

Ligaments Key: N = Normal A = Abnormal

- ACL (e.g. anterior drawer test) N A N A

- MCL N A N A

- LCL N A N A

Any other locomotor abnormalities? No Yes

Skin Doctor to comment on abnormal results

Scars e.g. surgical No Yes

Any evidence of eczema, dermatitis? No Yes

Any evidence of other dermatological conditions? No Yes

Abdomen Doctor to comment on abnormal results

Is there any evidence of disease of the abdomen and/or alimentary tract? No Yes

Is there any evidence of a past or present hernia? No Yes

Urinalysis Doctor to comment on abnormal results

Glucose Nil Trace + ++ +++ >3+

Protein/albumin Nil Trace + ++ +++ >3+

Blood Nil Trace + ++ +++ >3+

Applicant Name: ……........................……………………….....…



Summary

1. Please comment on any abnormality not noted elsewhere:

Yes Do you advise any further investigations?

Reasons:

2. No

Sensitive: Personal

SECTION 4 – DOCTOR TO COMPLETE

**Only this page is to be submitted to the NSW Rural Fire Service with application.** **Applicant to retain full completed medical.**

NSW RFS Specialist Functions & Physical Capability Assessment

14 of 14NSW RURAL FIRE SERVICE

Having reviewed the provided Information Sheets (relevant NSW RFS Role Profile, Physical Capability Assessment) please provide your opinion on the applicant’s suitability to undertake the specialist functions including the physical capability assessments for specialist functions within the NSW RFS.

Please carefully consider - cardiac risk, musculoskeletal status and any other active health conditions (e.g. exercised induced asthma) before sign off

**If unsure please mark the second option ‘Not currently cleared’ **

Cleared to undertake specialist functions and physical capability assessment

Not currently cleared: fitness to undertake specialist functions and physical assessment. Further medical

assessments required.

Applicant Name: ……........................……………………….....…

CONTACT DETAILS AND SIGNATURE OF DOCTOR PERFORMING THE EXAMINATION

Name

Postal address

Telephone

Date

Doctor’s stamp

Fax

Signature

APPLICANT’S DETAILS

Family Name First Name

Middle Name Date of Birth (DD-MM-YYYY)

-

-

Male Female

Street Address

Suburb State Postal Code

Daytime Contact Telephone Number (Home / Work)

( )Phone (Mobile)

Email (preferred method of contact – print clearly in capitals)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

@ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ . _ _

Brigade District:

-

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