Form Cg-719k - Medical Evaluation Report Page 7
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9Page 7 of 9 of CG-719K Rev. 01-09
Section VII (a) - Physical Information
This section to be completed by the verifying medical practitioner, or other medical staff to the satisfaction of the verifying
medical practitioner. Additional information must be reported in Section VII.
Height (inches only):
Weight (lbs):
Body Mass Index (BMI): Gender:
Pulse Resting:
Initial Blood Pressure:
Repeat Blood Pressure (if needed):
Section VII (b)– Physical Exam
(must be completed by verifying medical practitioner)
#
Normal
Abnormal
System/Organ
#
Normal
Abnormal
System/Organ
Head, Face, Neck, Scalp
Skin
1.
10.
Eyes / Pupils / EOM
Lymphatic
2.
11.
Mouth And Throat
Neurologic
3.
12.
Ears / Drums
Vascular System
4.
13.
Lungs And Chest
Genital-Urinary System
5.
14.
Heart
Hernia
6.
15.
Missing extremities / Digits
Abdomen
7.
16.
Upper / Lower Extremities
General / Systemic
8.
17.
Spine / Musculoskeletal
9.
Please make numbered comments on abnormal systems/organs:
Section VIII - Demonstration of Physical Ability
(to be completed by the verifying medical practitioner)
► If the examining medical practitioner doubts the applicant’s ability to meet the guidelines contained within this table, and
for all applicants with a Body Mass Index (BMI) of 40.0 or higher, the practitioner shall require that the applicant
demonstrate the ability to meet the guidelines. This does not mean, for example, that the applicant must actually don an
exposure suit, pull an uncharged 1.5 inch diameter 50’ fire hose with nozzle to full extension, or lift a charged 1.5 inch
diameter fire hose to fire fighting position. Rather, the medical practitioner may utilize alternative measures to satisfy
himself or herself that the applicant possesses the ability to meet the guidelines in the third column. A description of the
methods utilized by the medical practitioner should be reported in Section IX.
► All practical demonstrations, if required, should be performed by the applicant without assistance. Any prosthesis
normally worn by the applicant, and other aid devices, may be used by the applicant in all practical demonstrations
except when the use of such items would prevent the proper wearing of mandated personal protection equipment (PPE).
Applicant Name: _______________________________________
Date of Birth:____________________________
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