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Pulmonary Function / Respirator Fit Test

Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory) 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? Yes  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.
Part A. Section. (Mandatory)  The following information must be provided by every employee who has been selected to use any type of respirator .
Today's Date:	TODAY'S DATE: Month January February March Aprill May June July August September October November December TODAY'S DATE: DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 TODAY'S DATE: Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Full Name:
Your age (to the nearest year):
Sex:	Male   Female
Height / Weight:	0 1 2 3 4 5 6 7 8 Feet 0 1 2 3 4 5 6 7 8 9 10 11 Inches  - Weight Pounds
Job Title:
Phone Number:	A phone number where you can be reached by the health care professional who reviews this questionnaire (include area code)
Best Time to Call:	(best time to call you at the number above)
Contact Health Care Professional:	1.    Has your employer told you how to contact the health care professional who will review this questionnaire? YES or NO Yes No
1.     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) Other type (for example, half-or full-face piece type, powered-air purifying, supplied-air, self contained breathing apparatus) 1.    Have you worn a respirator:  YES or NO Yes No If “If you answered "Yes” above 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 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month:  YES or NO Yes No 2. Have you ever had any of the following conditions?  a.     Seizures (fits): YES or NO Yes No b.     Diabetes (sugar disease): YES or NO Yes No c.     Allergic reactions that interfere with your breathing: YES or NO Yes No d.     Claustrophobia (fear of closed-in places): YES or NO Yes No e.     Trouble smelling odors: YES or NO Yes No 3. Have you ever had any of the following pulmonary or lung problems? a.     Asbestosis: YES or NO Yes No b.     Asthma: YES or NO Yes No c.     Chronic bronchitis: YES or NO Yes No d.     Emphysema: YES or NO Yes No e.     Pneumonia: YES or NO Yes No f.      Tuberculosis: YES or NO Yes No g.     Silicosis: YES or NO Yes No h.     Pneumothorax (collapsed lung): YES or NO Yes No i.      Lung cancer: YES or NO Yes No j.      Broken ribs: YES or NO Yes No k.     Any chest injuries or surgeries: YES or NO Yes No l.      Any other lung problem that you've been told about: YES or NO Yes No 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a.     Shortness of breath: YES or NO Yes No b.     Shortness of breath when walking fast on level ground or walking up a slight hill or incline: YES or NO Yes No c.     Shortness of breath when walking with other people at an ordinary pace on level ground: YES or NO Yes No d.     Have to stop for breath when walking at your own pace on level ground: YES or NO Yes No e.     Shortness of breath when washing or dressing yourself: YES or NO Yes No f.      Shortness of breath that interferes with your job: YES or NO Yes No g.     Coughing that produces phlegm (thick sputum): YES or NO Yes No h.     Coughing that wakes you early in the morning: YES or NO Yes No i.      Coughing that occurs mostly when you are lying down: YES or NO Yes No j.      Coughing up blood in the last month: YES or NO Yes No k.     Wheezing: YES or NO Yes No l.      Wheezing that interferes with your job: YES or NO Yes No m.   Chest pain when you breathe deeply: YES or NO Yes No n.     Any other symptoms that you think may be related to lung problems: YES or NO Yes No 5. Have you ever had any of the following cardiovascular or heart problems? a.     Heart attack: YES or NO Yes No b.     Stroke: YES or NO Yes No c.     Angina: YES or NO Yes No d.     Heart failure: YES or NO Yes No e.     Swelling in your legs or feet (not caused by walking): YES or NO Yes No f.      Heart arrhythmia (heart beating irregularly): YES or NO Yes No g.     High blood pressure: YES or NO Yes No h.     Any other heart problem that you've been told about: YES or NO Yes No 6. Have you ever had any of the following cardiovascular or heart symptoms? a.     Frequent pain or tightness in your chest: YES or NO Yes No b.     Pain or tightness in your chest during physical activity: YES or NO Yes No c.     Pain or tightness in your chest that interferes with your job: YES or NO Yes No d.     In the past two years, have you noticed your heart skipping or missing a beat: YES or NO Yes No e.     Heartburn or indigestion that is not related to eating: YES or NO Yes No f.      Any other symptoms that you think may be related to heart or circulation problems: YES or NO Yes No 7. Do you currently take medication for any of the following problems? a.     Breathing or lung problems: YES or NO Yes No b.     Heart trouble: YES or NO Yes No c.     Blood pressure: YES or NO Yes No d.     Seizures (fits): YES or NO Yes No If you've never used a respirator, check this box and please go directly to question 9 8. If you've used a respirator, have you ever had any of the following problems? a.     Eye irritation: YES or NO Yes No b.     Skin allergies or rashes: YES or NO Yes No c.     Anxiety: YES or NO Yes No d.     General weakness or fatigue: YES or NO Yes No e.     Any other problem that interferes with your use of a respirator: YES or NO Yes No 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? YES or NO Yes No Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-face piece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary. 10. Have you ever lost vision in either eye (temporarily or permanently): YES or NO Yes No 11. Do you currently have any of the following vision problems? a.     Wear contact lenses: YES or NO Yes No b.     Wear glasses: YES or NO Yes No c.     Color blind: YES or NO Yes No d.     Any other eye or vision problem: YES or NO Yes No 12. Have you ever had an injury to your ears, including a broken ear drum: YES or NO Yes No 13. Do you currently have any of the following hearing problems? a.     Difficulty hearing: YES or NO Yes No b.     Wear a hearing aid: YES or NO Yes No c.     Any other hearing or ear problem: YES or NO Yes No 14. Have you ever had a back injury: YES or NO Yes No 15. Do you currently have any of the following musculoskeletal problems? a.     Weakness in any of your arms, hands, legs, or feet: YES or NO Yes No b.     Back pain: YES or NO Yes No c.     Difficulty fully moving your arms and legs: YES or NO Yes No d.     Pain or stiffness when you lean forward or backward at the waist: YES or NO Yes No e.     Difficulty fully moving your head up or down: YES or NO Yes No f.      Difficulty fully moving your head side to side: YES or NO Yes No g.     Difficulty bending at your knees: YES or NO Yes No h.     Difficulty squatting to the ground: YES or NO Yes No i.      Climbing a flight of stairs or a ladder carrying more than 25 lbs: YES or NO Yes No j.      Any other muscle or skeletal problem that interferes with using a respirator: YES or NO Yes No If you'd like to start over you can hit the "reset" button to clear the form.    PLEASE SIGN BELOW:   X                                                                                               Please diligently recheck your answers before signing. 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