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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.

First page of Medical Examination Report

"Medical examination report
Title of position
Date of Birth Month   Day   Year

Height (without shoes) ___ ft. ___ in.
Weight  ___ lb. Has weight changed within the last year? Gained ___ lb Lost ___ lb
Eyes: Left 20/__   Right 20/___   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
Flat Feet
Hammer Toes
Hernia (actual or potential)
Varicose Veins
Spinal Curvature
Extremity defects
Hearing 20/
Evidences of previous operations
Disabilities: (Chronic, catarrh, sinus, rectal diseases, etc.)

Clinical Report:
Wasserman (or Kahn)
Urinalysis: Sugar
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

Page 2 of Medical Examination Report

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, arthiritis, [illegible], rheumatism, syphilis, tumor, cancer, goitre, tuberculosis, rectal trouble or mastoiditis?
e) Including any kind of hernia, bodily deformity, impaired vision or hearing, or any illness, injury of impairment not already mentioned?

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