Respirator Medical Evaluation Questionnaire-Part A Form Page 3
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3Respirator Medical Evaluation Questionnaire-Part A
Name: _________________________________ DOB: _____________ Date: ______________________
9. Would you like to talk to the health care professional who will review this questionnaire about your
answers to this questionnaire: Yes/No
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece
respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other
types of respirators, answering these questions is voluntary.
OHS use only
_______________________
10. Have you ever lost vision in either eye (temporarily or permanently): Yes/No
_______________________
11. Do you currently have any of the following vision problems?
_______________________
a.
Wear contact lenses: Yes/No
_______________________
b.
Wear glasses: Yes/No
_______________________
c.
Color blind: Yes/No
_______________________
d.
Any other eye or vision problem: Yes/No
_______________________
_______________________
12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No
_______________________
_______________________
13. Do you currently have any of the following hearing problems?
_______________________
a.
Difficulty hearing: Yes/No
_______________________
b.
Wear a hearing aid: Yes/No
c.
Any other hearing or ear problem: Yes/No
_______________________
_______________________
14. Have you ever had a back injury: Yes/No
_______________________
_______________________
15. Do you currently have any of the following musculoskeletal problems?
_______________________
a.
Weakness in any of your arms, hands, legs, or feet: Yes/No
_______________________
b.
Back pain: Yes/No
_______________________
c.
Difficulty fully moving your arms and legs: Yes/No
_______________________
d.
Pain or stiffness when you lean forward or
_______________________
backward at the waist: Yes/No
_______________________
e.
Difficulty fully moving your head up or down: Yes/No
f.
Difficulty fully moving your head side to side: Yes/No
g.
Difficulty bending at your knees: Yes/No
h.
Difficulty squatting to the ground: Yes/No
i.
Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No
j.
Any other muscle or skeletal problem that interferes with using a respirator: Yes/No
Signature: __________________________________________________________ Date: _________________
Reviewed by: ________________________________________________________Date:_________________
Cleared□
Follow-up required□_________________________________________________________________________
For clinician use only: Part B completed? Yes/No
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