Respirator Medical Evaluation Questionnaire Template printable pdf download

RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE

This form is used to determine whether or not you have a medical condition that may affect your ability to wear a

respirator. The form must be completed in full and will be reviewed by University Health Services. If you have any

questions regarding this information, please contact UHS at (215) 955-6835. Your health information will remain

confidential. All completed forms will be maintained in your UHS medical record only.

NAME: ____________________________________________________

DOB: ___________________

(PLEASE PRINT)

(REQUIRED)

HOME PHONE: _____________________________________________

MALE FEMALE

BEST TIME TO PHONE: ___________________________

Work extension: ___________

JOB TITLE/DEPT/UNIT: _______________________________________________________________________

Please circle one:

Jefferson Employee

Agency/Traveler

Jefferson Student – Program: _________________

Height: _____________

Weight: ___________

Have you worn a respirator in the past? Yes No

IF YES, WHAT TYPE? __________________________________

Have you been fit tested at Jefferson in the past? Yes No

IF NO, PLEASE PROCEED TO SECTION A AND COMPLETE BOTH SIDES OF THE FORM.

If you have been fit tested at Jefferson in the past, have you had any significant changes in your health since your last fit test?

Yes No

IF NO, PLEASE SIGN BELOW AND GIVE THIS FORM TO UNIVERSITY HEALTH SERVICES.

IF YES, PLEASE PROCEED TO SECTION A , COMPLETE BOTH SIDES OF THE FORM, AND GIVE THIS

FORM TO UNIVERSITY HEALTH SERVICES.

I verify by my signature below that the above statements are true to the best of my knowledge.

_____________________________________________

________________________

Signature

Today’s Date

SECTION A

Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes No

Please check below if you have ever had any of the following conditions:

__ Seizures

__ Diabetes

__ Allergic reactions that interfere with your breathing

__ Claustrophobia

__ Trouble smelling odors

Please check below if you have ever had any of the following pulmonary or lung problems:

__ Asbestosis

__ Asthma

__ Chronic bronchitis

__ Emphysema

__ Pneumonia

__ Tuberculosis

__ Silicosis

__ Pneumothorax (collapsed lung)

__ Lung cancer

__ Broken ribs

__ Any chest injuries or surgeries

__ Any other lung problem that you’ve been told about

Description: _______________________________

Please check below if you currently have any of the following symptoms of pulmonary or lung illness:

__ Shortness of breath

__ Shortness of breath when walking fast on level ground or walking up a slight hill or incline

Respirator Medical Evaluation Questionnaire Template

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