Respirator (N 95, Papr) Medical Evaluation Questionnaire (Page 2 of 2) in pdf

YES

g. Coughing that produces phlegm (thick sputum)

h. Coughing that wakes you early in the morning

i. Coughing that occurs mostly when you are lying down

j. Coughing up blood in the last month

k. Wheezing

1. Wheezing that interferes with your job

m. Chest pain when you breathe deeply

n. Any other symptoms that you think may be related to lung problems

7. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack

b. Stroke

c. Angina

d. Heart failure

e. Swelling in your legs or feet (not caused by walking)

f. Heart arrhythmia (heart beating irregularly)

g. High blood pressure

h. Any other heart problem that you've been told about: _____________________________

8. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest

b. Pain or tightness in your chest during physical activity

c. Pain or tightness in your chest that interferes with your job

d. In the past two years, have you noticed your heart skipping or missing a beat

e. Heartburn or indigestion that is not related to eating

f. Any other symptoms that you think may be related to heat or circulation problems

9. Do you currently take medication for any of the following problems?

a. Breathing or lung problems

b. Heart trouble

c. Blood pressure

d. Seizures (fits)

If YES, please list medication:

10. If you've used a respirator, have you ever had any of the following problems?

(Skip this question if you haven’t used a respirator)

a. Eye irritation

b. Skin allergies or rashes

c. Anxiety

d. General weakness or fatigue

e. Any other problem that interferes with your use of a respirator

Signature:______________________________________________ Date: ______/______/______

For Health Care Provider:

SIGNATURE of reviewer:____________________________________Date____/____/____

Responses Reviewed, Approved for Fit Testing _______

Further Medical Evaluation Required _______

Comments: __________________________________________________________________________________________

6.12.15

Page 2 of 2

Respirator (N 95, Papr) Medical Evaluation Questionnaire Page 2

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