• Respirator Medical Evaluation Questionnaire

    Respirator Medical Evaluation Questionnaire

  • Privacy Disclaimer

    At Medfit Solutions, we are committed to protecting your privacy. We want to assure you that any personal or health-related information you provide will be kept strictly confidential. We do not sell, share, or disclose personal or health data to third parties for marketing or advertising purposes. Your information is used solely for the purposes of providing services, and meeting legal or regulatory obligations.

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

  • Date*
     - -
  • Format: (000) 000-0000.
  • Has your employer told you how to contact the health care professional who will review this questionnaire?*
  • Have you worn a respirator before? (example: N95, Half-Face, Full-Face or SCBA (power-air purifying, supplied-air, self-contained breathing apparatus)

  • Part A. Section2. (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?*

  • 2. Have you ever had any of the following conditions?

  • 2a. Seizures*
  • 2b. Diabetes (sugar disease)*
  • 2c. Allergic reactions that interfere with your breathing*
  • 2d. Claustrophobia (fear of closed-in places)*
  • 2e. Trouble smelling odors*

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

  • 3a. Asbestosis*
  • 3b. Asthma*
  • 3c. Chronic bronchitis*
  • 3d. Emphysema*
  • 3e. Pneumonia*
  • 3f. Tuberculosis*
  • 3g. Silicosis*
  • 3h. Pneumothorax (collapsed lung)*
  • 3i. Lung Cancer*
  • 3j. Broken Ribs*
  • 3k. Any chest injuries or surgeries*
  • 3l. Any other lung problem that you've been told about*

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

  • 4a. Shortness of breath*
  • 4b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline*
  • 4c. Shortness of breath when walking with other people at an ordinary pace on level ground*
  • 4d. Have to stop for breath when walking at your own pace on level ground*
  • 4e. Shortness of breath when washing or dressing yourself*
  • 4f. Shortness of breath that interferes with your job*
  • 4g. Coughing that produces phlegm (thick sputum)*
  • 4h. Coughing that wakes you early in the morning*
  • 4i. Coughing that occurs mostly when you are lying down*
  • 4j. Coughing up blood in the last month*
  • 4k. Wheezing*
  • 4l. Wheezing that interferes with your job*
  • 4m. Chest pain when you breathe deeply*
  • 4n. Any other symptoms that you think may be related to lung problems*

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

  • 5a. Heart Attack*
  • 5b. Stroke*
  • 5c. Angina*
  • 5d. Heart Failure*
  • 5e. Swelling in your legs of feet (not caused by walking)*
  • 5f. Heart arrhythmia (heart beating irregularly)*
  • 5g. High blood pressure*
  • 5h. Any other heart problem that you've been told about*

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

  • 6a. Frequent pain or tightness in your chest*
  • 6b. Pain or tightness in your chest during physical activity*
  • 6c. Pain or tightness in your chest that interferes with your job*
  • 6d. In the past two years, have you noticed your heart skipping or missing a beat*
  • 6e. Heartburn or indigestion that is not related to eating*
  • 6f. Any other symptoms that you think may be related to heart or circulation problems*

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

  • 7a. Breathing or lung problems*
  • 7b. Heart trouble*
  • 7c. Blood Pressure*
  • 7d. Seizures*

  • 8. Since you selected "Yes" on using a respirator before in Section 1, have you ever had any of the following problems?

  • 8a. Eye Irritation*
  • 8b. Skin allergies or rashes*
  • 8c. Anxiety*
  • 8d. General weakness or fatigue*
  • 8e. Any other problem that interferes with your use of a resipirator*
  • 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?*

  • Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece 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)?*

  • 11. Do you currently have any of the following vision problems?

  • 11a. Wear contact lenses*
  • 11b. Wear glasses*
  • 11c. Color blind*
  • 11d. Any other eye or vision problem*
  • 12. Have you ever had an injury to your ears, including a broken eardrum?*

  • 13. Do you currently have any of the following hearing problems?

  • 13a. Difficulty hearing*
  • 13b. Wear a hearing aid*
  • 13c. Any other hearing or ear problem*
  • 14. Have you ever had a back injury?*

  • 15. Do you currently have any of the following musculoskeletal problems?

  • 15a. Weakness in any of your arms, hands, legs, or feet*
  • 15b. Back pain*
  • 15c. Difficulty fully moving your arms and legs*
  • 15d. Pain and stiffness when you lean forward or backward at the waist*
  • 15e. Difficulty fully moving your head up or down*
  • 15f. Difficulty fully moving your head side to side*
  • 15g. Difficulty bending at your knees*
  • 15h. Difficulty squatting to the ground*
  • 15i. Climbing a flight of stairs or a ladder carrying more than 25 lbs*
  • 15j. Any other muscle or skeletal problem that interferes with using a respirator*
  • Should be Empty: