Mine Rescue Team Member Physicians Examination Form Page 2

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Examination (Must be completed by a licensed physician)
DOB:____________ Weight:__________ Height:____________
*Blood Pressure:________/_________
*Repeated blood pressure (controlled or uncontrolled by medication) reading which exceeds 160 systolic, or 100
diastolic, or which is less than 105 systolic, or 60 diastolic.
** Pulse Rate: Standing__________
After Exercise__________ After two (2) minutes rest__________
**The pulse rate should be taken for a full minute as follows: (a) While the applicant is standing; (b) While the
applicant is standing after making a step test (18 in. high, 15 times in 30 seconds); (c) After the applicant has been
sitting down two (2) minutes following the step test. If the third pulse rate exceeds by two beats per minute the
first pulse rate, the applicant is not physically fit to wear breathing apparatus.
Nose: □Normal □Abnormal
Throat: □Normal □Abnormal
Abdomen: □Normal □Abnormal
Heart: □Normal □Abnormal
Chest: □Normal □Abnormal
Hernia:
□Yes
□No
Eyes: (Distant visual acuity without glasses) Right eye_______ Left eye________
Hearing Loss: Hearing loss without a hearing aid greater than 40 decibels at 400, 1,000 and 2, 000 Hz
Right ear__________ decibels
Left ear__________ decibels
Yes
No
Does patient have any history of seizure disorder?
Does patient have heart disease?
Does patient have heart disease as shown by an EKG?
Does patient have any missing limbs or hands?
Does patient have a perforated eardrum?
Does patient have any condition which is relevant to whether he or she is fit for mine rescue
team service? (If yes, Describe)__________________________________________
I certify that I have examined the Individual listed above, and determined that he/she is
physically fit to perform mine rescue and recovery work for prolonged periods under strenuous
conditions.
_______________________________
______________________
Physician’s Name (please type or print)
Address
________________________________
____________________
□
□
Physician’s Signature
Date
MD
DO
(Revised 01/2012)

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