Respirator Medical Evaluation Questionnaire-Part A Form
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Respirator Medical Evaluation Questionnaire-Part A
Occupational Health Services
169 Riverside Drive
Binghamton, NY 13905
607-251-2170
Fax 607-251-2012
The information provided is CONFIDENTIAL.
The following information must be provided by every employee who has been selected to use any type of respirator
(please print).
1. Your name: _________________________________________________2. Date of birth:_____________________
3. Sex (circle one): Male/Female 4. Height: _________ft. ________ in. 5. Your weight: __________lbs.
6. Your job title: _______________________7. Company/Department_________________________________________
8. A phone number where you can be reached by the health care professional who reviews this questionnaire:
(daytime)________________________________ (evening) _____________________________
9. Check the type of respirator you will use (you can check more than one category):
a. _____N, R, or P disposable respirator (filter-mask, non-cartridge type only).
b. _____Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self
contained breathing apparatus) _________________________________________________________________
10. Have you worn a respirator (circle one): Yes/No
If “yes,” what type(s):____________________
Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator
(please circle “yes” or “no”).
If you answer yes to any question, please provide date of diagnosis, duration, list of medications or last episode in
the comment section at the end of this questionnaire.
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No
OHS use only
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
________________________
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