Firefighters And Police Officers Limited Heart Examination {OD-4}

Firemen And Police Officer's Limited Heart Examination Form Name (Last, First, Middle) Sex Date of Examination Address Age Date of Birth Personal Physician's Name Occupation PHYSICAL HEIGHT WEIGHT BLOOD PRESSURE OVERWEIGHT? YES NO EKG NORMAL ABNORMAL (Specify) STETHOSCOPIC EXAMINATION OF THE HEART NORMAL ABNORMAL (Specify) 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-4 (rev. 7/99) American LegalNet, Inc. www.FormsWorkFlow.com