Respirator Medical Evaluation Questionnaire


eMail:
Name:
S.S. #:
Company:
Date of Birth:
Sex:	Male Female
Height:
Weight:	lbs.
Job Title:
Phone number where you can be reached by health care professional:
Best time to call you at the number above:
Do you know, what type of respirator you will wear?	Yes No
If "yes" please check the type of respirator you will use(you can check more than one category):
A. N, R, or P disposable respirator (filter mask, non-cartridge type only). B. Other type (for example, half- or full-face piece type, powered air purifying, supplied-air, self contained breathing apparatus.
Have you worn a respirator in the past?	Yes No
If "yes" what type(s)?:

Part A. Section 2 (Mandatory) (Please answer every question in this section by checking "yes" or "no").
Do you currently smoke tobacco, or have you smoked tobacco in the last month?	Yes No
If "yes", how much do you smoke and for how long?

Have you ever had any of the following conditions?
A. Seizures (fits):	Yes No
B. Diabetes(sugar disease):	Yes No
C. Allergic reactions that interfere with breathing:	Yes No
D. Claustrophobia (fear of closed-in places):	Yes No
E. Trouble smelling odors:	Yes No

Have you ever had any of the following pulmonary or lung problems?
A. Asbestosis:	Yes No
B. Asthma:	Yes No
C. Chronic bronchitis:	Yes No
D. Emphysema:	Yes No
E. Pneumonia:	Yes No
F. Tuberculosis:	Yes No
G. Silicosis:	Yes No
H. Pneumothorax(collapsed lung):	Yes No
I. Lung Cancer:	Yes No
J. Broken Ribs:	Yes No
K. Any chest injuries or surgeries:	Yes No
L. Any other lung problem that you've been told about:	Yes No

Do you currently have any of the following symptoms of pulmonary or lung illness?
A. Shortness of Breath:	Yes No
B. Shortness of Breath when walking fast on level ground or at an incline:	Yes No
C. Shortness of Breath when walking at ordinary pace on level ground:	Yes No
D. Have to stop for breath when walking at your pace on level ground:	Yes No
E. Shortness of breath when washing or dressing yourself:	Yes No
F. Shortness of breath that interferes with your job:	Yes No
G. Coughing that produces phlegm(thick sputum):	Yes No
H. Coughing that wakes you early in the morning:	Yes No
I. Coughing that occurs mostly when you are lying down:	Yes No
J. Coughing up blood in the last month:	Yes No
K. Wheezing:	Yes No
L. Wheezing that interferes with your job:	Yes No
M. Chest pain when you breathe deeply:	Yes No
N. Any other symptoms that you think may be related to lung problems:	Yes No
Have you ever had any of the following cardiovascular or heart problems?
A. Heart Attack:	Yes No
B. Stroke:	Yes No
C. Angina:	Yes No
D. Heart Failure:	Yes No
E. Swelling in your legs or feet(not caused by walking):	Yes No
F. Heart arrhythmia(heart beating irregularly):	Yes No
G: High blood pressure:	Yes No
H. Any other heart problem that you've been told about:	Yes No
I. If "Yes", please list:

Have you ever had any of the following cardiovascular or heart symptoms?
A. Frequent pain or tightness in your chest:	Yes No
B. Pain or tightness in your chest during physical activity:	Yes No
C. Pain or tightness in your chest that interferes with your job:	Yes No
D. In the past two years, have you noticed your heart skipping or missing a beat:	Yes No
E. Heartburn or indigestion that is not related to eating:	Yes No
F. Any other symptoms that you think may be related to heart or circulation problems:	Yes No

Do you currently take medication for any of the following problems?
A. Breathing or lung problems:	Yes No
B. Heart trouble:	Yes No
C. Blood Pressure:	Yes No
D. Seizures(fits):	Yes No

If you've used a respirator, have you ever had any of the following problems? If you've never used a respirator, Please check this box and go on to next section.
A. Eye irritation:	Yes No
B. Skin allergies or rashes:	Yes No
C. Anxiety:	Yes No
D. General weakness or fatigue:	Yes No
E. Any other problem that interferes with your use of a respirator:	Yes No

Would you like to talk to the health care professional who will review your answers to this questionnaire? Yes No

Have you ever lost vision in either eye(temporarily or permanently): Yes No

Have you had either:

A. Repeated episodes of lost vision?	Yes No
B. Permanent loss of vision in either eye?	Yes No
C. Permanent loss of vision resulting in a change in lifestyle?	Yes No

Do you have any of the following vision problems?
A. Wear contact lenses:	Yes No
B. Wear glasses:	Yes No
C. Color Blind:	Yes No
D. Any other eye or vision problem:
Have you ever had an injury to your ears, including a broken eardrum?	Yes No

Do you currently have any of the following hearing problems?
A. Difficulty hearing:	Yes No
B. Wear a hearing aid:	Yes No
C. Any other hearing or ear problem:	Yes No
Have you ever had a back injury?	Yes No

Do you currently have any of the following muscle/skeletal problems?
A. Weakness in any of your arms, hands, legs, or feet:	Yes No
B. Back Pain:	Yes No
C: Difficulty fully moving your arms and legs:	Yes No
D: Pain or stiffness when you lean forward or backward at the waist:	Yes No
E. Difficulty fully moving your head up or down:	Yes No
F. Difficulty fully moving your head side to side:	Yes No
G. Difficulty bending at your knees:	Yes No
H. Difficulty squatting to the ground:	Yes No
I. Difficulty climbing a ladder or a flight of stairs or a ladder carrying more than 25lbs.:	Yes No
J. Any other muscle or skeletal problem that interferes with using a respirator:
Will you be wearing protective clothing or equipment when you're using your respirator?	Yes No
If "yes", describe this protective clothing or equipment:
Do you understand all the questions listed here?	Yes No
Would you like to discuss this questionnaire with the Licensed Healthcare Professional administering it?	Yes No

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