Respirator Medical Evaluation Questionnaire-Part A Form Page 2
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3Respirator Medical Evaluation Questionnaire-Part A
Name: _________________________________ DOB: _____________ Date: ______________________
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
f.
Shortness of breath that interferes with your job: Yes/No
OHS use only
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
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
8. If you’ve used a respirator, have you ever had any of the following problems?
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
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