PHS Occupational Health Service

RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE

You have been identified as having a job that may require you to wear a respirator. Prior to wearing a respirator you must be screened to determine whether you have a medical condition that may affect your ability to safely and comfortably wear one.

Please complete the following questions. The Occupational Health Service will treat all information you provide in a confidential manner.

Please print your answers in pen. Thank you.

PART 1: EMPLOYEE INFORMATION

1). Today’s Date: / /

2). LastName:______First Name: ______

3). Age (to the nearest year):______4). Date of Birth (mm/dd/yy): / /

5). Sex: Male Female 6). Height: _____ feet _____ inches

7). Weight (inpounds): ______8). Job Title: ______

9). Employee ID #:______10). Department/Service: ______

11). Supervisor’s Name: ______12). Extension/Beeper:______

13). Medical Record #:______14). Hazmat Team Member: Yes No

15).Check the type of respirator you have been advised you will be using (Please check all categories

that apply):

Disposable respirator (N-95 filter mask)

Half or full face piece type

Powered Air Purifying type (PAPR)

Self-contained breathing apparatus (SCBA)

16). Have you worn a respirator before?: Yes, what type(s):______

No

PART 2: MEDICAL HISTORY
Question 1 / Do you currently smoke tobacco or have you smoked tobacco in the last month? Yes No
If yes to the above, please complete the following:
Age Started Age Stopped # Per Day
a. cigarettes ______
b. cigars ______
c. pipes ______
Question 2 / Have you ever had any of the following conditions? / Yes / No
a. Seizures (fits)
b. Diabetes (blood sugar disease)
c. Allergic reactions that interfere with your breathing
d. Claustrophobia (fear of enclosed spaces)
e. Trouble smelling odors
Question 3 / Have you ever had any of the following pulmonary or lung problems? / Yes / No
a. Asbestosis
b. Asthma (If yes, please also complete “Asthma History” PART 3)
c. Chronic bronchitis
d. Emphysema
e. Pneumonia
f. Tuberculosis (TB)
g. Silicosis
h. Pneumothorax (collapsed lung)
i. Lung cancer
j. Broken rib(s)
k. Any chest injury or surgery
l. Any other lung problem not listed here that you have been told about
Question 4 / Do you currently have any of the following symptoms of pulmonary or lung disease? / Yes / No
a. Shortness of breath
b. Shortness of breath when walking fast on level ground or up a slight
hill or incline
c. Shortness of breath when walking with other people at an ordinary
pace on level ground
d. Have to stop for breath when walking at your own pace on level
ground
e. Shortness of breath when washing or dressing yourself
f. Shortness of breath that interferes with your job
g. Coughing that produces phlegm (thick mucus or sputum)
h. Coughing that wakes you early in the morning
i. Coughing that occurs mostly when you are lying down
j. Wheezing
k. Wheezing that interferes with your job
l. Chest pain when you breathe deeply
m. Any other symptoms that you think may be related to lung problems
If you checked yes to any of the above (questions a- m) please list the letter of the item you answered yes to on the line and then answer the question next to it. Please do this for each item for which you answered yes:
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Question 5 / Have you ever had any of the following cardiovascular or heart problems? / Yes / No
a. Heart attack
b. Stroke
c. Angina
d. Heart failure
e. Swelling in your legs or feet (not caused by walking)
f. Heart arrhythmia (heart beating irregularly)
g. High blood pressure
If you checked “Yes”, is your blood pressure currently in normal
range? Yes No
When was the last time your blood pressure was checked?
______
h. Any other heart problem that you’ve been told about
If you checked yes to any of the above (questions a- g) please list the letter of the item you answered yes to on the line and then answer the question next to it. Please do this for each item for you which you answered yes:
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Question 6 / Have you ever had any of the following cardiovascular or heart symptoms? / Yes / No
a. Frequent pain or tightness in your chest
b. Pain or tightness in your chest during physical activity
c. Pain or tightness in your chest that interferes with your job
d. In the past two years, have you noticed your heart skipping or missing
a beat
e. Heartburn or indigestion that is not related to eating
f. Any other symptoms that you think may be related to heart or
circulation problems
If you checked yes to any of the above (questions a- f) please list the letter of the item you answered yes to on the line and then answer the question next to it. Please do this for each item for which you answered yes:
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Item ____ Have you been medically evaluated for this? Yes No
Question 7 / Do you currently take medications for any of the following problems? / Yes / No
a. Breathing or lung problems
b. Heart trouble
c. Blood pressure
d. Seizures
Question 8 / If you have used a respirator before, have you ever had any of the following problems while wearing a respirator? Also, if you checked “Yes”, please indicate if you currently experience any of these problems while wearing a respirator?
(If you have never used a respirator please check this box and go to Question 9.) / Yes / No
a. Eye irritation/Difficulty with clear vision
Currently? Yes No
b. Skin allergies or rashes Currently? Yes No
c. Anxiety/nervousness Currently? Yes No
d. General weakness or fatigue Currently? Yes No
e. Poor Fit Currently? Yes No
e. Any other problem that interferes with your use of a respirator

Question 9: Do you have a beard or mustache? Yes No

Question 10: Would you like to talk to the Nurse Practitioner who will review this questionnaire

about your answerslisted on this questionnaire? Yes No

If yes, what is the best number to reach you: ______

What is the best time of day to call? ______

PART 3: ASTHMA HISTORY

Please complete the following questions if you have ever been told you have asthma or if you have experienced symptoms of asthma as an adult. If this does not apply to you please go directly to Part 4 below.

Question 1 / In the last month, have you had asthma symptoms (cough, wheeze, Yes No
shortness of breath, chest tightness) more than twice a week?
Question 2 / In the last month, have asthma symptoms woken you up at night or Yes No
earlier than usual in the morning more than twice?
Question 3 / In the last month, have you used your rescue inhaler Yes No
(such as albuterol) more than twice?
Question 4 / If you currently use a respirator is it difficult to wear when you Yes No
have asthma symptoms?

PART 4: OTHER

If you will be using a full face-piece respirator or a self-contained breathing apparatus (SCBA) please complete the section below. If you will be using another type of respirator answering these questions is voluntary.

Question 1 / Have you ever lost vision in either eye (temporarily or permanently)? / Yes / No
Question 2 / Do you currently have any of the following vision problems? / Yes / No
a. Wear contact lenses
b. Wear glasses
c. Color Blindness or Deficiency
d. Any other eye or vision problem If “Yes” please describe:
Question 3 / Do you currently have any of the following hearing problems? / Yes / No
a. Difficulty Hearing
b. Wear a hearing aid
c. Any other hearing or ear problem
d. Any injury to the ears, including broken eardrum
Question 4 / Have you ever had a back injury? / Yes / No
Question 5 / Do you currently have any of the following musculoskeletal problems? / Yes / No
a. Weakness in any of your arms, hands, legs, or feet
b. Back pain
c. Difficulty fully moving your arms and legs
d. Pain or stiffness when you lean forward or backward at the waist
e. Difficulty fully moving your head up and down
f. Difficulty fully moving your head side to side
g. Difficulty bending at your knees
h. Difficulty squatting to the ground
i. Climbing a flight of stairs or a ladder carrying more than 25 lbs.
j. Any other muscle or skeletal problem that interferes with using a
respirator
PART 5: OHS Use Only
______
OHS Reviewer Date
Cleared Without Restrictions for:
Cleared With Restrictions for:
 N95  PAPR  SCBA  Dust/Fume
Half-face Negative Pressure Air Purifying (Canister Type)
Full-face Negative Pressure Air Purifying (Canister Type)
RecommendedFrequency of Use (check the appropriate frequency on each line):
 0 – 5 Hrs/Week  6 – 20 Hrs/Week  >20 Hrs/Week
 < 30 Minutes/Use At Once  30 – 60 Minutes/Use At Once  > 60 Minutes/Use At Once
Restrictions: ______
Rescreening Frequency:
 1 Year  2 Years  3 Years  4 Years  5 Years
 No rescreening necessary unless health changes
Requires PE/PFTs Per Protocol Prior To Clearance Determination (see PE sheet for additional determination)
Not Approved
Pending PCP or Treating Specialist Recommendation: / / Date of Request
Pending OHS Physician Review
Smoking Cessation Materials To Be Sent
Check That Employee Is Member Of Hazmat Team
Comments (Additional History, Status of Physician Recommendation/Review):

1

9/06