Respirator (N 95, Papr) Medical Evaluation Questionnaire printable pdf download

NIVERSITY OF

ALIFORNIA

RANCISCO

TUDENT

EALTH AND

OUNSELING

ERVICE

RESPIRATOR (N 95, PAPR) MEDICAL EVALUATION

This questionnaire will be used in determining whether or not you have a medical condition that may affect your ability

to wear a respirator. All medical information is considered confidential.

Name: ______________________________________________________

Sex: M / F / Trans

Date of Birth: __________________

Age: ______ Height: __ ____

Weight: __________

Department or school: ___________________

Phone number: _________________

1. Check the type of respirator you will use:

Disposable Respirator (N 95—Used for TB/SARS pt care) _________

Other Type ____________________________

Please check appropriate box below

YES

2. Have you worn a respirator before?

If “yes,” what type(s): __________________________________________

3. Do you currently smoke tobacco, or have you smoked in the last month?

4. Have you ever had any of the following conditions?

a. Seizures (fits)

b. Diabetes (sugar disease)

c. Allergic reactions that interfere with your breathing

d. Claustrophobia (fear of closed-in places)

e. Trouble smelling odors

5. Have you ever had any of the following pulmonary or lung problems?

a. Asbestosis

b. Asthma/Silicosis

c. Chronic bronchitis

d. Emphysema

e. Pneumonia

f. Tuberculosis (this does NOT include PPD positive status)

g. Pneumothorax (collapsed lung)

h. Lung cancer

i. Broken ribs

j. Any chest injuries or surgeries

k. Any other lung problem that you’ve been told about: _____________________________

6. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath

b. Shortness of breath when walking fast on level ground or walking up a slight hill / incline

c. Shortness of breath when walking with other people at an ordinary pace on level ground

d. Have to stop for breath when walking at your own pace on level ground

e. Shortness of breath when washing or dressing yourself

f. Shortness of breath that interferes with your job

6.12.15

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Respirator (N 95, Papr) Medical Evaluation Questionnaire

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