OSHA Respirator Medical Evaluation Questionnaire (Mandatory) UVA-WorkMed

Today's date

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:

Your full name (First name, middle initial, last name) (Required)

Your age (Required)

Your gender (Required)

Female
Male

Your height in feet & inches (Required)

Your weight (Required)

A phone number where you can be reached by the health care professional who reviews this questionnaire. (Required)

The best time to phone you at this number:

Check the type of respirator you will use: (Required)

(you can check more than one category)

N disposable respirator (filter-mask, non- cartridge type only)

R disposable respirator (filter-mask, non- cartridge type only)

P disposable respirator (filter-mask, non- cartridge type only).

Other type

Don't know

Have you worn a respirator? (Required)

YES
NO

If "yes," what type(s)?

Do you currently smoke tobacco, or have you smoked tobacco in the last month? (Required)

YES
NO

Have you ever had seizures? (Required)

YES
NO

Have you ever had diabetes? (Required)

YES
NO

Have you ever had allergic reactions that interfere with your breathing? (Required)

YES
NO

Have you ever had claustrophobia (fear of closed-in places)? (Required)

YES
NO

Have you ever had trouble smelling odors? (Required)

YES
NO

Have you ever had asbestosis? (Required)

YES
NO

Have you ever had asthma? (Required)

YES
NO

Have you ever had chronic bronchitis? (Required)

YES
NO

Have you ever had emphysema? (Required)

YES
NO

Have you ever had pneumonia? (Required)

YES
NO

Have you ever had tuberculosis? (Required)

YES
NO

Have you ever had silicosis? (Required)

YES
NO

Have you ever had pneumothorax? (Required)

YES
NO

Have you ever had lung cancer? (Required)

YES
NO

Have you ever had broken ribs? (Required)

YES
NO

Have you ever had any chest injuries or surgeries? (Required)

YES
NO

Have you ever had any other lung problem that you've been told about? (Required)

YES
NO

Do you currently have shortness of breath? (Required)

YES
NO

Do you currently have shortness of breath when walking fast on level ground or walking up a slight hill or incline? (Required)

YES
NO

Do you currently have shortness of breath when walking with other people at an ordinary pace on level ground? (Required)

YES
NO

Do you currently have to stop for breath when walking at your own pace on level ground? (Required)

YES
NO

Do you currently have shortness of breath when washing or dressing yourself? (Required)

YES
NO

Do you currently have shortness of breath that interferes with your job? (Required)

YES
NO

Do you currently have coughing that produces phlegm (thick sputum)? (Required)

YES
NO

Do you currently have coughing that wakes you early in the morning? (Required)

YES
NO

Do you currently have coughing that occurs mostly when you are lying down? (Required)

YES
NO

Have you coughed up blood in the last month? (Required)

YES
NO

Do you currently have wheezing? (Required)

YES
NO

Do you currently have wheezing that interferes with your job? (Required)

YES
NO

Do you currently have chest pain when you breathe deeply? (Required)

YES
NO

Do you currently have any other symptoms that you think may be related to lung problems? (Required)

YES
NO

Have you ever had a heart attack? (Required)

YES
NO

Have you ever had a stroke? (Required)

YES
NO

Have you ever had heart failure? (Required)

YES
NO

Have you ever had swelling in your legs or feet (not caused by walking)? (Required)

YES
NO

Have you ever had heart arrhythmia (heart beating irregularly)? (Required)

YES
NO

Have you ever had high blood pressure? (Required)

YES
NO

Have you ever had any other heart problem that you've been told about? (Required)

YES
NO

Have you ever had frequent pain or tightness in your chest? (Required)

YES
NO

Have you ever had pain or tightness in your chest during physical activity? (Required)

YES
NO

Have you ever had pain or tightness in your chest that interferes with your job? (Required)

YES
NO

In the past two years, have you noticed your heart skipping or missing a beat? (Required)

YES
NO

Have you ever had heartburn or indigestion that is not related to eating? (Required)

YES
NO

Have you ever had any other symptoms that you think may be related to heart or circulation problems? (Required)

YES
NO

Do you currently take medication for breathing or lung problems? (Required)

YES
NO

Do you currently take medication for heart trouble? (Required)

YES
NO

Do you currently take medication for blood pressure? (Required)

YES
NO

Do you currently take medication for seizures? (Required)

YES
NO

If you've used a respirator, have you ever had eye irritation?

YES
NO

If you've used a respirator, have you ever had skin allergies or rashes?

YES
NO

If you've used a respirator, have you ever had anxiety?

YES
NO

If you've used a respirator, have you ever had general weakness or fatigue?

YES
NO

If you've used a respirator, have you ever had any other problem that interferes with your use of a respirator?

YES
NO

Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? (Required)

YES
NO

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OSHA Respirator Medical Evaluation Questionnaire (Mandatory) UVA-WorkMed

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