OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134:

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 *

First

Last

Job Title *

Phone Number *

Date of Birth *

Sex: *

Male
Female
Prefer not to answer

Can you read English? *

Yes
No

Has 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. *

Yes
No

Check 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 type
Half-face
Full-facepiece type (includes gas mask)
Powered-air purifier
Supplied-air
Self-contained breathing apparatus

Have you worn a respirator in the past? *

Yes
No

If "yes," what type(s):

Physical exertion while wearing a respirator

Mild
Moderate
Strenuous

Maximum time you would wear a respirator in a single day (number of hours) *

Do you exercise? *

Yes
No

If "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? *

Yes
No

If yes, how many packs per day?

1/2 or less
1
2
2 or more

How many years have you smoked?

1-9
10-19
20-29
30 or more

2. Have you ever had any of the following conditions? (Check all that apply) *

Seizures (fits)
Diabetes (sugar disease)
Allergic reactions that interfere with your breathing
Claustrophobia (fear of closed-in places)
Trouble smellling odors
None

3. Have you ever had any of the following pulmonary or lung problems? (Check all that apply) *

Asbestosis
Asthma
Chronic bronchitis
Emphysema
Pneumonia
Tuberculosis
Silicosis
Pneumothorax (collapsed lung)
Lung cancer
Broken ribs
Any chest injuries or surgeries
Any other lung problem that you’ve been told about
None

4. Do you currently have any of the following symptoms of pulmonary or lung illness? (Check all that apply) *

Shortness of breath
Shortness of breath when walking fast on level ground or walking up a slight hill/incline
Shortness of breath when walking with other people at an ordinary pace on level ground
Have to stop for breath when walking at your own pace on level ground
Shortness of breath when washing or dressing yourself
Shortness of breath that interferes with your job
Coughing that produces phlegm (thick sputum)
Coughing that wakes you early in the morning
Coughing that occurs mostly when you are lying down
Coughing up blood in the last month
Wheezing
Wheezing that interferes with your job
Chest pain when you breathe deeply
Any other symptoms that you think may be related to lung
None

5. Have you ever had any of the following cardiovascular or heart problems? (Check all that apply) *

Heart attack
Stroke
Angina
Heart failure
Swelling in your legs and feet (not caused by walking)
Heart arrhythmia (heart beating irregularly)
High blood pressure
Any other heart problem that you’ve been told about
None

6. Have you ever had any of the following cardiovascular or heart symptoms? (Check all that apply) *

Frequent pain or tightness in your chest
Pain or tightness in your chest during physical activity
Pain or tightness in your chest that interferes with your job
In the past two years, you’ve noticed your heart skipping or missing a beat
Heartburn or symptoms that are not related to eating
Any other symptoms that you think may be related to heart or circulation problems
None

7. Do you currently take medication for any of the following problems? (Check all that apply) *

Breathing or lung problems
Heart trouble
Blood pressure
Seizures (fits)
None

8. 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 irritation
Skin allergies or rashes
Anxiety
General weakness or fatigue
Any other problem that interferes with your use of a respirator
N/A

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? *

Yes
No

Enter 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 *

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