Form Osha/uams-N95 - Respirator Medical Evaluation Questionnaire Page 2
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3OSHA Respirator Medical Questionnaire (pg 2) Name ___________________________
Part A. Section 2a. (Mark “yes” or “no”).
1.
Do you have asthma?…………...……………………………….
Yes
No
2.
If yes, is it controlled on medication?...........................................
Yes
No
3.
Do you have high blood pressure? ...............................................
Yes
No
4.
If yes, is it controlled on medication?..........................................
Yes
No
5.
Do you have heart disease? .........................................................
Yes
No
6.
If yes, does it decrease you ability to exercise or to work? .........
Yes
No
7.
Do you have chronic lung disease? .............................................
Yes
No
8.
If yes, does it decrease you ability to exercise or to work?..........
Yes
No
9.
Do you have seizures?..................................................................
Yes
No
10.
If yes, when was your last attack?
_____________________________
Part A. Section 2b. (Mark “yes” or “no”).
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?
Yes
No
2. Have you ever had any of the following conditions?
a. Seizures (fits): ……………………………………………………….
Yes
No
b. Diabetes (sugar disease): ……………………………………………
Yes
No
c. Allergic reactions that interfere with your breathing: ………………
Yes
No
d. Claustrophobia (fear of closed-in 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
j. Broken ribs: …………………………………………………………
Yes
No
k. Any chest injuries or surgeries: …………………………………….
Yes
No
l. Any other lung problem that you've 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 hill or
incline: ……………………………………………………………..
Yes
No
c. Shortness of breath when walking with other people at an ordinary pace on level
ground: ……………………………………………………………..
Yes
No
d. Have to stop for breath when walking at your own pace on level ground:
……………………………………………………………………....
Yes
No
e. Shortness of breath when washing or dressing yourself: …………..
Yes
No
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