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MEDICAL QUESTIONNAIRE FOR RESPIRATOR USERS

Employee:_______________________________________Job Title:________________________________

SS#: Date of Birth: Employer:__________________________________
Employer Phone Number: ____________________________________

Age: Height: Weight: _____________

Have you worn a respirator before? Yes No
If Yes, describe any difficulties noted with respirator use:____________________________________________
______________________________________________________________________________________
Will you be wearing any other personal protective equipment? Yes No
If Yes, please describe:____________________________________________________________________
Have you had or do you currently have any of the following:
1. Lung Disease Yes No
2. Persistent Cough Yes No
3. Heart Trouble Yes No
4. Shortness of Breath Yes No
5. History of Fainting/Seizures Yes No
6. High Blood Pressure Yes No
7. Diabetes Yes No
8. Feelings of Claustrophobia Yes No
9. Skin Problems/Abnormalities Yes No
10. Heat Exhaustion/Heat Stroke Yes No
11. Defective Vision Yes No
12. Defective Hearing Yes No
13. Asthma Yes No
14. Anemia Yes No
15. Epilepsy Yes No
16. Back Problems Yes No
17. Any other conditions which might interfere with respirator use Yes No

Please explain YES answers (use back of form if necessary)_________________________________________
______________________________________________________________________________________
Are you currently taking any medications? Yes No
If YES, please list:________________________________________________________________________
______________________________________________________________________________________
Do you now or have you ever smoked? Yes No
At what age did you start smoking?________________________________________
How long ago did you quit smoking?________________________________________
How many packs per day did or do you smoke? _______________________________

PHYSICIAN SIGNATURE EMPLOYEE SIGNATURE

DATE DATE

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