Free OD-3 - Nevada

Firemen And Police Officer's Extensive Heart Examination Form
Name (Last, First, Middle) Sex Date of Examination

Address

Age

Date of Birth

Personal Physician's Name

Occupation

PHYSICAL HEIGHT WEIGHT EKG NORMAL ABNORMAL (Specify) BLOOD PRESSURE OVERWEIGHT?
YES NO

STRESS EKG* NORMAL
*If 40 years old or older or if abnormalities with resting EKG and no contraindications to performing test exist.

ABNORMAL (Specify)

STETHOSCOPIC EXAMINATION OF THE HEART NORMAL ABNORMAL (Specify)
Cholesterol Urine Glucose

Triglycerides

It is recommended that you contact your personal physician for advice concerning correction of . . .

Examiner's Signature

Date

Please sign one copy of this form and submit it to your employer or organization.
Employee's Signature Date

Form OD-3 (rev. 7/99)