University of Alabama
Respirator Medical Evaluation Questionnaire
To the employee: Can you read? (Circle one): Yes/No
Your employer must allow you to answer this questionnaire during normal work hours,
or at a time and place that is convenient to you.
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).
Name: ________________________________________ Date: ____________________
Phone #: (____) ______________ the best time to reach you at this number: __________
Age (to nearest year): ___________ Sex: Male? Female? Height: ______ Weight: ____
1. If you need to contact the health care professional who will review this
questionnaire contact EHS (348-5905).
2. Have you worn a respirator? (circle one) Yes/ No
If yes, what type?
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 indicate
yes or no).
1. Do you currently smoke tobacco or have you in the last month?
__ Yes __ No
2. Have you ever had any of the following conditions?
a) Seizures
__ Yes __ No
b) Diabetes
__ Yes __ No
c) Allergic reactions that interfere with your breathing
__ Yes __ No
d) Claustrophobia (fear of enclosed places)
__ Yes__ No
e) Trouble smelling odors
__ Yes __ No
3. Have you ever had any of the following pulmonary or lung problems?
a) Asbestosis
__ Yes __ No
b) Asthma
__ Yes __ No
c) Chronic bronchitis
__ Yes __ No
d) Emphysema
__ Yes __ No
e) Pneumonia
__ Yes __ No
f) Tuberculosis
__ Yes __ No
g) Silicosis
__ Yes __ No
h) Pneumothorax (collapsed lung)
__ Yes __ No
i) Lung cancer
__ Yes __ No