Henderson & Associates, Inc

Henderson & Associates, Inc

OSHA Respiratory Protection Medical Questionnaire Form

Can you read? q Yes q No

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Name______Last 4 of Social Security Number______

Address______Phone Number______

FARM NAME______Today’s Date______

City and State and zip code______

Date of Birth______Sex (check one) q Male q Female

Your height______ft. ______in. Your weight______lbs.

Your job title______Your telephone number______

Best time to phone you______

Have you been told how to contact the health care professional who will review this questionnaire? X Yes q No

Check the type of respirator you will use (you can check more than one category):

  N, R, or P disposable respirator (filter-mask, non-cartridge type only)

X Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air,
self-contained breathing apparatus)

Have you worn a respirator before? X Yes q No

If “yes,” what type(s) are you being FIT for today _____FULL FACE______

How often and under what conditions do you expect to wear a respirator?

  Escape only (no rescue) q Emergency rescue only

X Less than 4 hours/week on average q Less than 4 hours/day on average

  More than 4 hours/day on average

Describe the work effort you will be required to use while wearing a respirator:

X Light q Moderate q Heavy

Describe the work you will be doing while wearing a respirator: TREATING FIELDS, MIXING CHEMICALS_____

Describe any other protective clothing or equipment you will be wearing when you wear a respirator:

RUBBER GLOVES, LONG PANTS, BOOTS

Describe any special or hazardous conditions you might encounter while wearing a respirator (e.g., confined spaces, high test, high humidity, etc.)

HIGH HEAT, HIGH HUMIDITY, CHEMICAL SPILLS

If you know them, describe the possible chemicals, gases, dusts, or toxic substances you might be exposed to while wearing a respirator:

Do you currently smoke tobacco or have you smoked tobacco in the last month? q Yes q No

List any current medications you are taking______

Respiratory Protection Medical Questionnaire Form

Have you EVER had any of the following? Do you CURRENTLY have the following?

(ANSWER ALL) (ANSWER ALL)

Emphysema q Yes q No Coughing that occurs mostly when you are lying down q Yes q No

Pneumonia q Yes q No Coughing up blood in the last month q Yes q No

Tuberculosis q Yes q No Wheezing q Yes q No

Silicosis q Yes q No Wheezing that interferes with your job q Yes q No

Pneumothorax (collapsed lung) q Yes q No Chest pain when you breathe deeply q Yes q No

Lung Cancer q Yes q No Other symptoms that you think may be q Yes q No

related to lung problems

Broken ribs q Yes q No Do you currently take medication for any of the following? q Yes q No

Any chest injuries or surgeries q Yes q No Breathing or lung problems q Yes q No

Any other lung problem that you’ve q Yes q No Heart trouble q Yes q No

been told about

Heart attack q Yes q No Blood pressure problems q Yes q No

Stroke q Yes q No Have you EVER had any of the following? (ANSWER ALL THAT APPLY)

Angina q Yes q No Trouble smelling odors q Yes q No

Heart failure q Yes q No Asbestosis q Yes q No

Swelling in your legs or feet q Yes q No Asthma q Yes q No

(Not caused by walking)

Heart arrhythmia (irregular heartbeat) q Yes q No Chronic bronchitis q Yes q No

High blood pressure q Yes q No Shortness of breath q Yes q No

Any other heart problem that you’ve q Yes q No Shortness of breath when walking fast on level q Yes q No

been told about Ground or walking up a slight hill or incline

Have you ever had any of the following q Yes q No Shortness of breath when walking with other people q Yes q No

cardiovascular or heart symptoms? At an ordinary pace on level ground

Frequent pain or tightness in chest q Yes q No Have to stop for breath when walking at your own q Yes q No

pace on level ground

Pain or tightness in your chest during q Yes q No Shortness of breath when washing or q Yes q No

physical activity dressing yourself

Pain or tightness in your chest that q Yes q No Shortness of breath that interferes with your job q Yes q No

interferes with your job

In the past 2 years, have you noticed q Yes q No Coughing that produces phlegm (thick sputum) q Yes q No

your heart skipping or missing a beat?

Heartburn or indigestion that is not q Yes q No Coughing that wakes you early in the morning q Yes q No

related to eating

Any other symptoms you think may be q Yes q No If you've used a respirator, have you ever had any of the following problems?
related to heart or circulation problems (ANSWER ALL)

Seizures (fits) q Yes q No Eye irritation q Yes q No

Diabetes (sugar disease) q Yes q No Skin allergies or rashes q Yes q No

Allergic reactions that interfere with q Yes q No Anxiety q Yes q No

your breathing

Claustrophobia (fear of closed in q Yes q No General weakness or fatigue q Yes q No

places)

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Any other problem that interferes with q Yes q No

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX your use of a respirator?

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Would you like to talk to the health care q Yes q No

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Professional who will review this

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Questionnaire about your answers?

______

Employee Signature and Date

Additional Questions Required if Respirator Use Includes Full-Facepiece or Self-Contained Breathing Apparatus (SCBA)

SUPPLEMENT

Have you ever lost vision in either q Yes q No Do you currently have any of the following

eye temporarily or permanently? musculoskeletal problems? (ANSWER ALL)

Do you currently have any of the Weakness in any of your arms, hands q Yes q No

following vision problems? legs, or feet

Wear contact lenses q Yes q No Back pain q Yes q No

Color blind q Yes q No Difficulty fully moving your arms and legs q Yes q No

Any other eye or vision problem q Yes q No Difficulty squatting to the ground q Yes q No

Have you ever had an injury to your q Yes q No Pain or stiffness when you lean forward q Yes q No

ears, including a broken ear drum? or backward at the waist

Do you currently have any of the Difficulty fully moving your head up or down q Yes q No

following hearing problems? (ANSWER ALL)

Difficulty hearing q Yes q No Difficulty fully moving your head side to side q Yes q No

Wear a hearing aid q Yes q No Difficulty bending at your knees q Yes q No

Any other hearing or ear problem q Yes q No Climbing a flight of stairs or ladder carrying q Yes q No

more than 25 lbs

Have you ever had a back injury? q Yes q No Any other muscle or skeletal problem that q Yes q No

interferes with using a respirator