Respirator Medical Evaluation Questionnaire (Page 3 of 4) in pdf

Respirator Medical Evaluation Questionnaire Page 3

d) Seizures

__ Yes __ No

If yes, name the medications if you know them: ______________________________

_____________________________________________________________________

7. If you’ve used a respirator, have you ever had any of the following problems?

* Never used a respirator_____

a) Eye irritation

__ Yes __ No

b) Skin allergies or rashes

__ Yes __ No

c) Anxiety

__ Yes __ No

d) General weakness or fatigue

__ Yes __ No

e) Any other problems that interferes with your use of a respirator __ Yes __ No

8. Would you like to talk to the health care professional who will review this

questionnaire?

__ Yes __ No

ASSESSMENT- TO BE COMPLETED BY A NURSE OR PHYSICIAN

___ Employee is cleared to perform job duties with use of a respirator

___ Employee needs an evaluation by a physician

___ Other recommendations;________________________________________

It should be noted that medical qualification for respirator use is dependent upon

proper fit testing and instruction regarding use and maintenance of respiratory

equipment.

___________________________________________

__________________

Nurse or Physician signature

Date

Respirator Medical Evaluation Questionnaire Page 3