Form Osha/uams-N95 - Respirator Medical Evaluation Questionnaire Page 3
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3OSHA Respirator Medical Questionnaire (pg 3) Name ___________________________
4. Continued—symptoms of pulmonary or lung illness?
f. Shortness of breath that interferes with your job: …………………..
Yes
No
g. Coughing that produces phlegm (thick sputum): …………………..
Yes
No
h. Coughing that wakes you early in the morning: …………………...
Yes
No
i. Coughing that occurs mostly when you are lying 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 or heart problems?
a. Heart attack: ………………………………………………………..
Yes
No
b. Stroke: ……………………………………………………………...
Yes
No
c. Angina: ……………………………………………………………..
Yes
No
d. Heart failure: ………………………………………………………..
Yes
No
e. Swelling in your legs or feet (not caused by walking): …………….
Yes
No
f. Heart arrhythmia (heart beating irregularly): ……………………….
Yes
No
g. High blood pressure: ………………………………………………..
Yes
No
h. Any other heart problem that you've been told about: ……………...
Yes
No
6. Have you ever had any of the following cardiovascular or heart symptoms?
a. Frequent pain or tightness in your chest: …………………………...
Yes
No
b. Pain or tightness in your chest during physical activity: …………...
Yes
No
c. Pain or tightness in your chest that interferes with your job: ………
Yes
No
d. In the past two years, have you noticed your heart skipping or missing a beat:
………………………………………………………………………
Yes
No
e. Heartburn or indigestion that is not related to eating: ……………...
Yes
No
f. Any other symptoms that you think may be related to heart or circulation problems:
……………………………………………………………………….
Yes
No
(if “yes”, please list)________________________________________
7. 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
d. Seizures (fits): ………………………………………………………
Yes
No
Please list the medication________________________________________________
8. If you've used a respirator, have you ever had any of the following problems? (If
you've never used a respirator, check the following space
and go to question 9:)
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 problem that interferes with your use of a respirator: …...
Yes
No
9. Would you like to talk to the health care professional who will review this
questionnaire about your answers to this questionnaire: ……………..
Yes
No
Revised 4/23/2010
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