OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE

(To be completed by employee)*

Note to the employer:
Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee:
Can you read (check one): Yes/No If the employee requies assistance with this questionnaire, please complete the following.

Employee assisted by

Phone #

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.

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print).

1.- Today's date:

2.- Your name:

3.- Your age (to nearest year):

4.- Sex: Male Female

5.- Your height: ft in.

6.- Your weight: lbs.

7.- Your job title:

8.- A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code):

9.- The best time to phone:

10.- Has your employer told you how to contact the health care professional who will review this questionnaire: Yes No

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

	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 pparatus).
	c. Self-contained Breathing Apparatus and supplied air respirator

12.- Have you worn a respirator: Yes No

If "yes," what type(s):

Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please check one "yes" or "no").

1.- Have you ever used a respirator: Yes No

2.- Has respirator use caused any of the following:
2a. Eye Irritation: Yes No
2b. Skin allergies or rashes: Yes No
2c. Anxiety, choking or hyperventilation (over-breathing): Yes No
2d. General weakness or fatigue when using a respirator: Yes No
2e. Any other problem that interferes with your use of a respirator?:

3.- Do you currently smoke tobacco, or have you smoked tobacco in the last month:
3a. Do you currently smoke tobacco, or have you ever smoked: Yes No
3b. Do you still smoke? Yes No
3c. Number of years smoked:

3d. Number of packs of cigarettes smoked per day?

Have you ever had any of the following conditions?

4.- Seizures: Yes No
4a. Within the last two(2) years? Yes No
4b. Are you currently under the care of MD for your seizures? Yes No
4c. Are your seizures under control? Yes No

5.- Diabetes (sugar disease): Yes No
5a. Are you currently under the care of MD for your diabetes? Yes No
5b. Is your diabetes under control? Yes No
5c. How do you control your diabetes?

6.- Allergic reactions that interfere with your breathing: Yes No

7.- Claustrophobia (fear of closed-in places): Yes No
7a. Does your respirator causes you claustrophobia? Yes No

8.- Trouble smelling odors: Yes No

9.- Unexplained loss of consciousness? Yes No
9a. Within the last two (2) years? Yes No

Have you ever had any of the following pulmonary or lung problems?

10.- Asbestosis: Yes No

11.-Asthma: Yes No
11a. Treated within the last two (2) years? Yes No
11b. Are you currently taking any Asthma medication? Yes No

12.- Chronic bronchitis: Yes No

13.- Emphysema: Yes No

14.- Pneumonia: Yes No
14a. Are you currently receiving treatment for pneumonia? Yes No
14b. Hast it been resolved? Yes No

15.- Tuberculosis: Yes No
15a. Have you received treatment? Yes No
15b. Hast it been resolved? Yes No

16.- Silicosis: Yes No

17.- Pneumothorax (collapsed lung): Yes No
17a. Have you received treatment? Yes No
17b. Hast it been resolved? Yes No

18.- Lung cancer: Yes No

19.- Broken ribs: Yes No
19a. Have you received treatment? Yes No
19b. Hast it been resolved? Yes No

20.- Any chest injuries or surgeries: Yes No
20a. Have you received treatment? Yes No
20b. Hast it been resolved? Yes No

21.- Any other lung problem that you've been told about: Yes No

Do you currently have any of the following symptoms of pulmonary or lung illness?

22.- Shortness of breath: Yes No

23.- Shortness of breath when walking fast on level
ground or walking up a slight hill or incline: Yes No

24.- Shortness of breath when walking with other
people at an ordinary pace on level ground: Yes No

25.- Have to stop for breath when walking at your
own pace on level ground: Yes No

26.- Shortness of breath when washing or dressing yourself: Yes No

27.- Shortness of breath that interferes with your job: Yes No

28.- Persistent cough (most days for three or more months per year)? Yes No

29.- Coughing that produces phlegm (thick sputum): Yes No

30.- Persistent phlegm (most days for three or more months per year)? Yes No

31.- Coughing that wakes you early in the morning: Yes No

32.- Coughing that occurs mostly when you are lying down: Yes No

33.- Coughing up blood in the last month: Yes No

34.- Wheezing: Yes No

35.- Wheezing that interferes with your job: Yes No

36.- Chest pain when you breathe deeply: Yes No

37.- Any other symptoms that you think may
be related to lung problems: Yes No
If so, describe:

Have you ever had any of the following cardiovascular or heart problems?

38.- Heart attack: Yes No
38a.- What was the date of your heart attack?

39.- Stroke: Yes No
39a. If yes, has your MD medically cleared you to
perform a job requiring a respirator? Yes No

40.- Angina: Yes No

41.- Heart failure: Yes No

42.- Swelling in your legs or feet (not caused by walking): Yes No

43.- Heart arrhythmia (heart beating irregularly or very fast): Yes No

44.- High blood pressure: Yes No
44a. Are you under the care of MD for high blood pressure? Yes No
44b. Is your blood pressure under control with medication? Yes No

45.- Any other heart problem that you've been told about: Yes No

Have you ever had any of the following cardiovascular or heart symptoms?

46.- Frequent pain or tightness in your chest: Yes No
46a. Within the last two years? Yes No

47.- Pain or tightness in your chest during physical activity: Yes No
47a. Within the last two years? Yes No

48.- Pain or tightness in your chest that interferes with your job: Yes No
48a. Within the last two years? Yes No

49.- In the past two years, have you noticed your
heart skipping or missing a beat: Yes No
49a. Have you seen a MD for this condition? Yes No
49b. Has your MD medically cleared you to perform
a job requiring a respirator? Yes No

50.- Heartburn or indigestion that is not related to eating: Yes No
50a. Within the last two years? Yes No

51.- Any other symptoms that you think may be related
to heart or circulation problems: Yes No

Do you currently take medication for any of the following problems?

52.- Breathing or lung problems: Yes No

53.- Heart trouble: Yes No

54.- Blood pressure: Yes No

55.- Seizures (fits): Yes No

56.- Diabetes (shot or pill)?

Miscellaneous

57.- Have you seen a doctor in the last year for a medical problem? Yes No

58.- Have you ever lost vision in either eye? Yes No
58a. Was it permanent? Yes No

59.- Do you currently have any of the following vision problems?
59a. Wear contact lenses: Yes No
59b. Wear glasses: Yes No
59c. Are you required to wear glasses while wearing a respirator? Yes No
59d. Color blind: Yes No

60.- Any other eye or vision problem: Yes No

61.- Have you ever had an injury to your ears, including
a broken ear drum: Yes No
61a. Is your ear drum still currently ruptured? Yes No

Do you currently have any of the following hearing problems?

62.- Difficulty hearing: Yes No

63.- Wear a hearing aid: Yes No

64.- Any other hearing or ear problem: Yes No

65.- Have you ever had a back injury: Yes No
65a. Does this injury make use of a respirator difficult? Yes No

Do you currently have any of the following musculoskeletal problems?

66.- Weakness in any of your arms, hands, legs, or feet: Yes No
66a. Does this currently make use of a respirator difficult? Yes No

67.- Back pain: Yes No
67a. Does this currently make use of a respirator difficult? Yes No

68.- Difficulty fully moving your arms and legs: Yes No
68a. Does this currently make use of a respirator difficult? Yes No

69.- Pain or stiffness when you lean forward or backward at the waist: Yes No
69a. Does this currently make use of a respirator difficult? Yes No

70.- Difficulty fully moving your head up or down: Yes No
70a. Does this currently make use of a respirator difficult? Yes No

71.- Difficulty fully moving your head side to side: Yes No
71a. Does this currently make use of a respirator difficult? Yes No

72.- Difficulty bending at your knees: Yes No
72a. Does this currently make use of a respirator difficult? Yes No

73.- Difficulty squatting to the ground: Yes No
73a. Does this currently make use of a respirator difficult? Yes No

74.- Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes No
74a. Does this currently make use of a respirator difficult? Yes No

75.- Any other muscle or skeletal problem that interferes
with using a respirator: Yes No
75a. Does this currently make use of a respirator difficult? Yes No

Would you like to talk to the health care professional who will reviews this questionnaire about your answers to this questionnaire? Yes No

The above answers have been supplied by me and are true to the best of my knowledge.

EMPLOYEE E-SIGNATURE (Type name and Initial):

DATE: