This is a sample medical exam report from the Municipal Fire Department Code of Canada handbook (1961). 

Each firefighter had to pass a medical in order to be hired or promoted within the Department. Questions to be answered covered topics such as family history of mental or nervous disorders, contact with a person with tuberculosis, and details of surgical history.

A typed document detailing medical tests performed by a physician

"MEDICAL EXAMINATION REPORT

Title of position          Date of Birth          

Month          Day          Year          

Name          Date

A. TO BE COMPLETED BY THE MEDICAL EXAMINER

  • Height (without shoes) ___ ft. ___ in.
  • Weight  ___ lb. Has weight changed within the last year? Gained ___ lb Lost ___ lb
  • Eyes: Left 20/___ Right 20/___  
  • Eyes: Both 20/____ Colour vision ___ 
  • Chest: Inspiration ___  Expiration ___ 
  • Lungs: Check for asthma, tuberculosis, bronchitis ___ 
  • Heart: Cardio-vascular system ___ 
  • Pulse rate ___  Blood pressure: Systolic ___ Diastolic ___ 
  • Genito-Urinary: Varicocele ___ Obesity ___ 
  • Hydrocele ___ Flat Feet ___ 
  • Kidneys ___ Hammer Toes ___ 
  • Hernia (actual or potential) ___ Varicose Veins ___ 
  • Spinal Curvature ___ Extremity defects ___ 
  • Nose ___ Hands ___ 
  • Hearing ___  20/___ Teeth ___ 
  • Evidences of previous operations ___ 
  • Disabilities: (Chronic, catarrh, sinus, rectal diseases, etc.) ___ 

CLINICAL REPORT

  • Wasserman (or Kahn) ___ Urinalysis: Sugar ___ 
  • X-ray ___ Albumin ___ 
  • Positive Findings and Remarks ___ 

I hereby certify that this is a true record of the examination of the above candidate and that I have found him (not) physically fit for the duties of

[Signature of] Medical Examiner 

Municipal Fire Department Code Canada 1961"

The second page of a medical test to be filled out by the patient

 

B. TO BE COMPLETED BY THE APPLICANT

1. Are you now or have you ever been associated with a tubercular person or have you a family history of mental or nervous disorders to the best of your knowledge and belief? (Give details)

2. To the best of your knowledge and belief have you ever had or been under observation for any disease or disorder:
a) Of the brain or nervous system (convulsions, nervous breakdown, insanity, loss of consciousness, spinal disease or paralysis included)?
b) Of the throat, lungs or chest (pleurisy, asthma or bronchitis included)?
c) Of the heart, blood vessels or abnormal blood pressure (palpitation or shortness of breath included)?
d) Of the stomach, intestines or liver (gall stones, ulcer or appendicitis included)?
e) Of the genitor-urinary organs (any kidney trouble, prostatitis, gonorrhea, diabetes, albumin or sugar in urine included)?
f) Including anemia, arthritis, neuritis, rheumatism, syphilis, tumor, cancer, goitre, tuberculosis, rectal trouble or mastoiditis?
g) Including any kind of hernia, bodily deformity, impaired vision or hearing, or any illness, injury of impairment not already mentioned?

3.
a) Have you ever had a surgical operation?
b) Have you ever had surgery advised and not performed?

4. Have you consulted a physician in the past ten years other than as above (including check-ups)?

5. Have you at any time had an examination by a psychiatrist?

6. What are the details of any “yes” answers to questions No. 2, No. 3, and No. 4.
Nature of Disorder, Month, Year, Duration, Result, Names and addresses of all Doctors and Hospitals

7. Are you in good health to the best of your knowledge and belief?

I certify that the information given in these answers is true

[Signature of] Applicant"

Municipal Fire Department Code Canada 1961

City of Thunder Bay Archives Series Number: 29 TBA: 2556-07

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