Respirator Medical Evaluation Questionnaire Page 2
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4j) Broken ribs
__ Yes __ No
k) Any chest injuries or surgeries
__ Yes __ No
l) Any other lung problems that you have been told about
__ Yes __ No
4. Do you currently have any of the following symptoms of pulmonary or lung
illness?
a) Shortness of breath
__ Yes __ No
b) Shortness of breath when walking fast on level ground or
walking up a slight incline
__ Yes __ No
c) Shortness of breath when walking at an ordinary pace with
other people on level ground
__ Yes __ No
d) Stop for breath when walking at normal pace on level ground
__ Yes __ No
e) Shortness of breath when washing or dressing yourself
__ Yes __ No
f) Shortness of breath that interferes with your job
__ Yes __ No
g) Coughing that produces phlegm
__ Yes __ No
h) Coughing that wakes you early in morning
__ Yes __ No
i) Coughing that occurs mostly when you are laying down
__ Yes __ No
j) Coughing up blood in the last month
__ Yes __ No
k) Wheezing
__ Yes __ No
l) Wheezing that interferes with your job
__ Yes __ No
m) Chest pain when you breathe deeply
__ Yes __ No
n) Any other symptoms that you think may be related to lung
problems
__ Yes __ No
5. Have you ever had any of the following cardiovascular, heart problems or
symptoms?
a) Heart attack
__ Yes __ No
b) Stroke
__ Yes __ No
c) Angina
__ Yes __ No
d) heart failure
__ Yes __ No
e) Swelling in your legs and feet (not from walking)
__ Yes __ No
f) Heart beating irregularly
__ Yes __ No
g) High blood pressure
__ Yes __ No
h) Any other heart problem that you have been told about
__ Yes __ No
i) frequent pain or tightness in chest
__ Yes __ No
j) Pain or tightness in chest during physical activity
__ Yes __ No
k) Pain or tightness in your chest that interferes with your job
__ Yes __ No
l) In the past 2 years, have you noticed you heart skipping a beat
__ Yes __ No
m) Heartburn or indigestion not related to eating
__ Yes __ No
n) Any other symptoms that you think may be related to heart or
circulation problems
__ Yes __ No
6. Do you currently take medication for any of the following problems?
a) Breathing or lung problems
__ Yes __ No
b) Heart trouble
__ Yes __ No
c) Blood pressure
__ Yes __ No
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