OSHA Respirator Medical Evaluation Questionnaire

Mercyhealth Respiratory Protection Program

Confirmation:

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the healthcare professional who will review it.

This form after completion will be sent to, held, and maintained by Employee Health. The completed form will be reviewed by Employee Health in conjunction with Occupational Health.
By checking the box below, I attest that I have read the above statement and that my employer has followed the requirement above appropriately as it relates to the OSHA Respiratory Medical Evaluation. *

By checking the box below, I attest that I have read the above statement and that my employer has followed the requirement above appropriately as it relates to the OSHA Respiratory Medical Evaluation. I attest.
Part A. Section 1

The following information must be provided by every employee who has been selected to use any type of respirator.
Employee ID # *
Name Name * First Last
Email *
Today's Date Today's Date * / MM / DD YYYY
Your age (to nearest year) *
Gender *

Gender Male Female
Your height (example 5' 4'') *
Your weight (lbs) *
Your job title *
A phone number where you can be reached by health care professional who reviews this questionnaire. (Please include the Area Code) A phone number where you can be reached by health care professional who reviews this questionnaire. (Please include the Area Code) * - ### - ### ####
What is the best time to call you at this number?
Has your employer told you how to contact the healthcare professional who will review this questionnaire: *

Has your employer told you how to contact the healthcare professional who will review this questionnaire: Yes No
How to contact the healthcare professional
Employee Health reviews OSHA respirator questionnaires. Please reach out to Employee Health with any questions through email or phone. E: emphealth@mhemail.org P: 608-756-6502
The type of respirator you will use
You will be fitted with a 'N' disposable respirator This respirator is a half-face piece type
Have you worn a respirator in the past? *

Have you worn a respirator in the past? Yes No
Please tell us about the type of respirator you have worn? *
Part A. Section 2

Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please answer "yes" or "no")
Do you currently smoke tabacco, or have you smoked tabacco in the last month? *

Do you currently smoke tabacco, or have you smoked tabacco in the last month? Yes No

Have you ever had any of the following conditions? *
	Yes	No
Seizures (fits):	Seizures (fits):Yes	Seizures (fits):No
Diabetes (surgar disease):	Diabetes (surgar disease):Yes	Diabetes (surgar disease):No
Allergic reaction that interfere with your breathing:	Allergic reaction that interfere with your breathing:Yes	Allergic reaction that interfere with your breathing:No
Claustrophobia:	Claustrophobia:Yes	Claustrophobia:No
Trouble smelling odors	Trouble smelling odorsYes	Trouble smelling odorsNo

Please explain those marked as (yes) *

Have you ever had any of the following pulmonary or lung problems? *
	Yes	No
Asbestosis:	Asbestosis:Yes	Asbestosis:No
Asthma:	Asthma:Yes	Asthma:No
Chronic bronchitis:	Chronic bronchitis:Yes	Chronic bronchitis:No
Emphysema:	Emphysema:Yes	Emphysema:No
Pneumonia:	Pneumonia:Yes	Pneumonia:No
Tuberculosis:	Tuberculosis:Yes	Tuberculosis:No
Silicosis	SilicosisYes	SilicosisNo
Pneumothorax (collapsed lung):	Pneumothorax (collapsed lung):Yes	Pneumothorax (collapsed lung):No
Lung cancer:	Lung cancer:Yes	Lung cancer:No
Broken ribs:	Broken ribs:Yes	Broken ribs:No
Any chest injuries or surgeries:	Any chest injuries or surgeries:Yes	Any chest injuries or surgeries:No
Any other lung problems:	Any other lung problems:Yes	Any other lung problems:No

Please explain those marked as (yes) *

Do you currently have any of the following symptoms of pulmonary or lung illness? *
	Yes	No
Shortness of breath:	Shortness of breath:Yes	Shortness of breath:No
Shortness of breath when walking fast on level ground or walking up a slight hill or incline:	Shortness of breath when walking fast on level ground or walking up a slight hill or incline:Yes	Shortness of breath when walking fast on level ground or walking up a slight hill or incline:No
Shortness of breath when walking with other people at an ordinary pace on level ground:	Shortness of breath when walking with other people at an ordinary pace on level ground:Yes	Shortness of breath when walking with other people at an ordinary pace on level ground:No
Have to stop for breath when walking at your own pace on level ground:	Have to stop for breath when walking at your own pace on level ground:Yes	Have to stop for breath when walking at your own pace on level ground:No
Shortness of breath when washing or dressing yourself:	Shortness of breath when washing or dressing yourself:Yes	Shortness of breath when washing or dressing yourself:No
Shortness of breath that interferes with your job:	Shortness of breath that interferes with your job:Yes	Shortness of breath that interferes with your job:No
Coughing that wakes you early in the morning:	Coughing that wakes you early in the morning:Yes	Coughing that wakes you early in the morning:No
Coughing that occurs mostly when you are laying down:	Coughing that occurs mostly when you are laying down:Yes	Coughing that occurs mostly when you are laying down:No
Coughing up blood in the last month:	Coughing up blood in the last month:Yes	Coughing up blood in the last month:No
Wheezing:	Wheezing:Yes	Wheezing:No
Wheezing that interferes with your job:	Wheezing that interferes with your job:Yes	Wheezing that interferes with your job:No
Chest pain when you breathe deeply:	Chest pain when you breathe deeply:Yes	Chest pain when you breathe deeply:No
Any other symptoms that you think may be related to lung problems:	Any other symptoms that you think may be related to lung problems:Yes	Any other symptoms that you think may be related to lung problems:No

Please explain those marked as (yes) *

Have you ever had any of the following cardiovascular or heart symptoms? *
	Yes	No
Frequent pain or tightness in your chest:	Frequent pain or tightness in your chest:Yes	Frequent pain or tightness in your chest:No
Pain or tightness in your chest during physical activity:	Pain or tightness in your chest during physical activity:Yes	Pain or tightness in your chest during physical activity:No
Pain or tightness in your chest that interferes with your job:	Pain or tightness in your chest that interferes with your job:Yes	Pain or tightness in your chest that interferes with your job:No
In the past two years, have you noticed your heart skipping or missing a beat	In the past two years, have you noticed your heart skipping or missing a beatYes	In the past two years, have you noticed your heart skipping or missing a beatNo
Heartburn or indigestion that is not related to eating:	Heartburn or indigestion that is not related to eating:Yes	Heartburn or indigestion that is not related to eating:No
Any other symptoms that you think may be related to a heart or circulation problem:	Any other symptoms that you think may be related to a heart or circulation problem:Yes	Any other symptoms that you think may be related to a heart or circulation problem:No

Please explain those marked as (yes) *

Have you ever had any of the following cardiovascular or heart problems? *
	Yes	No
Heart attack:	Heart attack:Yes	Heart attack:No
Stroke:	Stroke:Yes	Stroke:No
Angina:	Angina:Yes	Angina:No
Heart Failure:	Heart Failure:Yes	Heart Failure:No
Swelling your legs or feet (not caused by walking):	Swelling your legs or feet (not caused by walking):Yes	Swelling your legs or feet (not caused by walking):No
Heart arrhythmia (heart beating irregularly):	Heart arrhythmia (heart beating irregularly):Yes	Heart arrhythmia (heart beating irregularly):No
High blood pressure:	High blood pressure:Yes	High blood pressure:No
Any other heart problem that you've been told about:	Any other heart problem that you've been told about:Yes	Any other heart problem that you've been told about:No

Please explain those marked as (yes) *

Do you currently take medication for any of the following problems? *
	Yes	No
Breathing or lung problems:	Breathing or lung problems:Yes	Breathing or lung problems:No
Heart trouble:	Heart trouble:Yes	Heart trouble:No
Blood pressure:	Blood pressure:Yes	Blood pressure:No
Seizures (fits):	Seizures (fits):Yes	Seizures (fits):No

Please explain those marked as (yes) *

If you have used a respirator, have you ever had any of the following problems?
	Yes	No
Eye irritation:	Eye irritation:Yes	Eye irritation:No
Skin allergies or rashes:	Skin allergies or rashes:Yes	Skin allergies or rashes:No
Anxiety:	Anxiety:Yes	Anxiety:No
General weakness or fatigue:	General weakness or fatigue:Yes	General weakness or fatigue:No
Any other problem that interferes with your use of a respirator:	Any other problem that interferes with your use of a respirator:Yes	Any other problem that interferes with your use of a respirator:No

Please explain those marked as (yes) *
Would you like to talk to the healthcare professional who will review this questionnaire about your answers to this questionnaire (if yes, the healthcare professional will call you): *

Would you like to talk to the healthcare professional who will review this questionnaire about your answers to this questionnaire (if yes, the healthcare professional will call you): Yes No

OSHA Respirator Medical Evaluation Questionnaire

OSHA Respirator Medical Evaluation Questionnaire

Confirmation:

Part A. Section 1

Part A. Section 2