Respirator Medical Evaluation Questionnaire









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in


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a. N, R, or P disposable respirator (filter-mask, non-cartridge type only)b. Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus)

YesNo




YesNo

a. Seizures YesNo
b. DiabetesYesNo
c. AllergicYesNo
d. ClaustrophobiaYesNo
e. Trouble smelling odorsYesNo

a. AsbestosisYesNo
b. Asthma YesNo
c. Chronic bronchitisYesNo
d. EmphysemaYesNo
e. PneumoniaYesNo
f. TuberculosisYesNo
g. SilicosisYesNo
h. Pneumothorax YesNo
i. Lung cancerYesNo
j. Broken ribsYesNo
k. Any chest injuries or surgeries YesNo
l. Any other lung problem that you've been told aboutYesNo

a. Shortness of breathYesNo
b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline YesNo
c. Shortness of breath when walking with other people at an ordinary pace on level ground:YesNo
d. Have to stop for breath when walking at your own pace on level groundYesNo
e. Shortness of breath when washing or dressing yourselfYesNo
f. Shortness of breath that interferes with your jobYesNo
g. Coughing that produces phlegm YesNo
h. Coughing that wakes you early in the morning YesNo
i. Coughing that occurs mostly when you are lying downYesNo
j. Coughing up blood in the last month:YesNo
k. Wheezing YesNo
l. Wheezing that interferes with your jobYesNo
m. Chest pain when you breathe deeply YesNo
n. Any other symptoms that you think may be related to lung problems:YesNo

a. Heart attackYesNo
b. StrokeYesNo
c. AnginaYesNo
d. Heart failureYesNo
e. Swelling in your legs or feetYesNo
f. Heart arrhythmiaYesNo
g. High blood pressureYesNo
h. Any other heart problem that you've been told about YesNo

a. Frequent pain or tightness in your chestYesNo
b. Pain or tightness in your chest during physical activityYesNo
c. Pain or tightness in your chest that interferes with your jobYesNo
d. In the past two years, have you noticed your heart skipping or missing a beatYesNo
e. Heartburn or indigestion that is not related to eatingYesNo
f. Any other symptoms that you think may be related to heart or circulation problemsYesNo

a. Breathing or lung problemsYesNo
b. Heart troubleYesNo
c. Blood pressureYesNo
d. SeizuresYesNo

a. Eye irritationYesNo
b. Skin allergies or rashesYesNo
c. Anxiety that occurs only when you use the respiratorYesNo
d. Unusual weakness or fatigueYesNo
e. Any other problem that interferes with your use of a respiratorYesNo

YesNo

10. Have you ever lost vision in either eyeYesNo

a. Wear contact lensesYesNo
b. Wear glassesYesNo
c. Color blindYesNo
d. Any other eye or vision problemYesNo

YesNo

a. Difficulty hearingYesNo
b. Wear a hearing aidYesNo
c. Any other hearing or ear problemYesNo
Any other eye or vision problemYesNo

YesNo

a. Weakness in any of your arms, hands, legs, or feetYesNo
b. Back painYesNo
c. Difficulty fully moving your arms and legsYesNo
d. Pain or stiffness when you lean forward or backward at the waistYesNo
e. Difficulty fully moving your head up or downYesNo
f. Difficulty fully moving your head side to side:YesNo
g. Difficulty bending at your kneesYesNo
h. Difficulty squatting to the groundYesNo
i. Difficulty climbing a flight of stairs or a ladder carrying more than 25 lbsYesNo
j. Any other muscle or skeletal problem that interferes with using a respiratorYesNo


1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal
amounts of oxygen YesNo
If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms
when you're working under these conditionsYesNo
2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g.,
gases, fumes, or dust), or have you come into skin contact with hazardous chemicals:YesNo




a. AsbestosYesNo
b. SilicaYesNo
c. Tungsten/cobaltYesNo
d. BerylliumYesNo
e. AluminumYesNo
f. CoalYesNo
g. IronYesNo
h. TinYesNo
i. Dusty environmentsYesNo
j. Any other hazardous exposuresYesNo





YesNo


YesNo

YesNo


a. HEPA FiltersYesNo
b. CanistersYesNo
c. CartridgesYesNo

a. Escape onlyYesNo
b. Emergency rescue onlyYesNo
c. Less than 5 hours per weekYesNo
d. Less than 2 hours per dayYesNo
e. 2 to 4 hours per dayYesNo
f. Over 4 hours per dayYesNo

a. LightYesNo


hrs


mins

YesNo


hrs


mins

YesNo


hrs


mins

YesNo


YesNo

YesNo














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