OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134: Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Part A. Section 1 – Every employee who has been selected to use any type of respirator must provide the following information. Today's Date *Name *FirstLastJob Title *Phone Number *Date of Birth *Sex: *MaleFemalePrefer not to answerCan you read English? *YesNoHas your employer told you how to contact the health care professional who will review this? Note: this form will be reviewed by our Clinical Director who can be reached at 720-274-5974. *YesNoCheck the type of respirator you will use (please check the first box for N, R or P disposable respirator) *N, R or P disposable respirator (filter-mask, non-catrtidge type only)Other typeHalf-faceFull-facepiece type (includes gas mask)Powered-air purifierSupplied-airSelf-contained breathing apparatusHave you worn a respirator in the past? *YesNoIf "yes," what type(s):Physical exertion while wearing a respiratorMildModerateStrenuousMaximum time you would wear a respirator in a single day (number of hours) *Do you exercise? *YesNoIf "yes," describe how often and what exercise activities:Part A. Section 2 – questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please select "yes" or "no") 1. Do you currently smoke tobacco or have you smoked tobacco in the last month? *YesNoIf yes, how many packs per day?1/2 or less122 or moreHow many years have you smoked?1-910-1920-2930 or more2. Have you ever had any of the following conditions? (Check all that apply) *Seizures (fits)Diabetes (sugar disease)Allergic reactions that interfere with your breathingClaustrophobia (fear of closed-in places)Trouble smellling odorsNone3. Have you ever had any of the following pulmonary or lung problems? (Check all that apply) *AsbestosisAsthmaChronic bronchitisEmphysemaPneumoniaTuberculosisSilicosisPneumothorax (collapsed lung)Lung cancerBroken ribsAny chest injuries or surgeriesAny other lung problem that you’ve been told aboutNone4. Do you currently have any of the following symptoms of pulmonary or lung illness? (Check all that apply) *Shortness of breathShortness of breath when walking fast on level ground or walking up a slight hill/inclineShortness of breath when walking with other people at an ordinary pace on level groundHave to stop for breath when walking at your own pace on level groundShortness of breath when washing or dressing yourselfShortness of breath that interferes with your jobCoughing that produces phlegm (thick sputum)Coughing that wakes you early in the morningCoughing that occurs mostly when you are lying downCoughing up blood in the last monthWheezingWheezing that interferes with your jobChest pain when you breathe deeplyAny other symptoms that you think may be related to lungNone5. Have you ever had any of the following cardiovascular or heart problems? (Check all that apply) *Heart attackStrokeAnginaHeart failureSwelling in your legs and feet (not caused by walking)Heart arrhythmia (heart beating irregularly)High blood pressureAny other heart problem that you’ve been told aboutNone6. Have you ever had any of the following cardiovascular or heart symptoms? (Check all that apply) *Frequent pain or tightness in your chestPain or tightness in your chest during physical activityPain or tightness in your chest that interferes with your jobIn the past two years, you’ve noticed your heart skipping or missing a beatHeartburn or symptoms that are not related to eatingAny other symptoms that you think may be related to heart or circulation problemsNone7. Do you currently take medication for any of the following problems? (Check all that apply) *Breathing or lung problemsHeart troubleBlood pressureSeizures (fits)None8. If you've used a respirator, have you ever had any of the following problems? (Check all that apply. If you've never used a respirator, please select N/A.) *Eye irritationSkin allergies or rashesAnxietyGeneral weakness or fatigueAny other problem that interferes with your use of a respiratorN/A9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? *YesNoEnter any additional comments you would like to make:The information above is true and accurate to the best of my knowledge. I understand that by typing my name below and clicking on "Submit," I am electronically signing this document. *Date * Submit