800 Cordova Street Anchorage, AK 99501
|Phone: (907) 222-7612
|Fax: (907) 222-6976
Date:
Respirator History Questionnaire
Last:
First:
SSN:
Date of Birth:
Company:
Job Title:
Check the type of respirator you will use (check all that apply):
Full
Have you worn a respirator?
Yes
No
If Yes, what type(s)?
Middle Initial:
Sex:
Male
Half
Job Location:
SCBA
Supplied Air
The following questions must be answered.
1.
2.
3.
4.
5.
6.
Female
Don’t Know
YES
NO
Do you currently smoke tobacco, or have you smoked tobacco in the last month?
Have you ever had any of the following conditions:
Seizures (or fits, epilepsy, convulsions)
Diabetes (sugar diabetes)
Allergic reactions that interfere with your breathing
Claustrophobia (fear of closed-in spaces)
Trouble smelling odors
Have you ever had any of the following pulmonary or lung problems:
Asbestosis
Asthma
Chronic bronchitis
Emphysema
Pneumonia
Tuberculosis
Pneumothorax (collapsed lung)
Lung Cancer
Broken Rib(s)
Any chest injuries
Any other lung problems/injuries?
Do you currently have any of the following symptoms or lung illness:
Shortness of breath
Shortness of breath when walking fast on level ground or walking up a slight hill or incline
Shortness of breath when walking with other people at an ordinary pace on level ground
Have to stop for breath when walking at your own pace on level ground
Shortness of breath when washing or dressing yourself
Coughing that produces phlegm
Coughing that wakes you early in the morning
Coughing that occurs mostly when you are lying down
Coughing up blood in the last month
Wheezing
Wheezing that interferes with your job
Chest pain when you take a deep breath
Any other symptoms that you think may be related to lung problems?
Have you ever had any of the following cardiovascular or heart problems:
Heart attack
Stroke
Angina
Heart failure
Swelling in your legs or feet (not caused by walking)
Heart arrhythmia (heart beating irregularly)
High blood pressure
Any other heart problem that you are aware of?
Have you ever had any of the following cardiovascular or heart problems:
Frequent pain or tightness in your chest
Pain or tightness in your chest during physical activity
In the past two years, have you noticed your heart skipping or missing a beat
Heartburn or indigestion that is not related to eating
Any other symptoms that you think may be related to heart or circulation problems?
15 – RESPIRATORY HISTORY QUESTIONNAIRE
JANUARY 1, 2010
PAGE 1 OF 4
YES
NO
7.
Do you currently take any medication for any of the following problems:
Blood pressure
Seizures (fits, convulsions, epilepsy)
Breathing or lung problems
Heart trouble?
8.
Have you used a respirator?
If NO, skip to question 9. If YES, have you ever had any of the following problems:
Eye irritation
Skin allergies or rashes
Anxiety
General weakness or fatigue
Any other problems that interfere with your use of a respirator?
9.
Would you like to talk to the provider about your answers to this questionnaire?
Answering the following questions to the best of your ability.
10. Have you ever lost vision in either eye (temporarily or permanently)?
11. Do you currently have any of the following vision problems:
Wear contact lenses
Wear glasses
Color blind
Any other eye or vision problems?
12. Have you ever had an injury to your ears, including a broken ear drum?
13. Do you currently have any of the following hearing problems:
Difficulty hearing
Wear a hearing aid
Any other hearing or ear problems?
14. Have you ever had a back injury?
15. Do you currently have any of the following musculoskeletal problems?
Weakness in any of your arms, hands, legs, or feet
Back pain
Difficulty fully moving your arms and legs
Pain or stiffness when you lean forward or backward at the waist
Difficulty fully moving your head up or down
Difficulty fully moving your head side to side
Difficulty bending at your knees
Difficulty squatting to the ground
Difficulty climbing a flight of stairs or a ladder carrying more than 25 pounds
Any other muscular or skeletal problems that might interfere with using a respirator
16. In your present job are you:
Working at high altitudes (over 5,000 feet)
In a place that has lower than normal amounts of oxygen
If YES, do you have feelings of dizziness, shortness of breath, pounding in your chest or other symptoms
when you are working under these conditions?
17. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals or
have you come into skin contact with hazardous chemicals?
If YES, please list the names of the chemicals:
18. Have you ever worked with any of the materials or under any of the conditions listed below:
Asbestos
Beryllium
Aluminum
Iron
Tin
Cadmium
Isocyanates
Silica (i.e. rock drilling/dust)
Tungsten/Cobalt (i.e. grinding or welding this material)
Coal dust (i.e. mining, power plants)
Any other hazardous exposures
Dusty environments
Welding fumes
Agricultural dust
If YES, please describe exposures below:
Patient Name:
15 – RESPIRATORY HISTORY QUESTIONNAIRE
Date:
JANUARY 1, 2010
PAGE 2 OF 4
19.
List any second jobs/side businesses you have:
20.
List previous occupations:
21.
List your current and previous hobbies:
22.
Have you been in the military services?
If YES, were you exposed to biological or chemical agents (either in training or combat)?
Have you ever worked on a HAZMAT team?
Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures
mentioned earlier in this questionnaire, are you taking any other medications for any reason (including overthe-counter medications)?
If YES, list the medications below:
YES
23.
24.
25.
26.
27.
Will you be using any of the following items with your respirator(s)?
HEPA filters
Canisters (i.e. gas masks)
Cartridges
How often are you expected to use the respirator(s)? Check all that apply.
Escape only (no rescue)
Emergency rescue only
Less than 5 hours per week
Less than 2 hours per day
2 – 4 hours per day
Over 4 hours per day
What types of work do you do during the period you are using the respirator(s)?
Light
If YES, how long does this period last during the average shift?
hours
NO
minutes
i.e. sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1 – 3 lbs.) or
controlling machines.
Moderate
If YES, how long does this period last during the average shift?
hours
minutes
i.e. sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or
transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5 degree grade about 3 mph;
or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.
Heavy
If YES, how long does this period last during the average shift?
28.
hours
minutes
i.e. lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while
bricklaying or chipping castings; walking up an 8 degree grade about 2 mph; or climbing stairs with a heavy load (about 50 lbs).
Will you be wearing protective clothing and/or equipment (other than the respirator) when using your
respirator?
If YES, describe this protective clothing and or equipment below:
29.
30.
31.
Will you be working under hot conditions (temperature exceeding 77° F)?
Will you be working under humid conditions?
Describe the work you will be doing while you are using your respirator(s):
32.
Describe any special or hazardous conditions you might encounter when you are using your respirator(s), for example, confined space, etc:
33.
Provide the following information for each toxic substance that you’ll be exposed to when using your respirator(s):
Name of the first toxic substance:
Duration of exposure per shift:
Estimated maximum exposure level per shift:
Name of the second toxic substance:
Duration of exposure per shift:
Estimated maximum exposure level per shift:
Name of the third toxic substance:
Duration of exposure per shift:
Estimated maximum exposure level per shift:
The name of any other toxic substances that you’ll be exposed to while using your respirator:
Patient Name:
15 – RESPIRATORY HISTORY QUESTIONNAIRE
Date:
JANUARY 1, 2010
PAGE 3 OF 4
34.
Describe any special responsibilities you will have while using your respirator(s) that may affect the safety and wellbeing of others (i.e.
records)
Please describe any positive responses to questions 1 – 15. Include medications and doses.
Question #
Detailed Description
I certify that I have completed the above questionnaire accurately and completely. I consent to a physical examination as required to determine
my ability to use respiratory equipment in conjunction with my employment. I understand that the written opinion as to my capability to use a
respirator will be conveyed to management.
Signature
Date
On-Site Examination
The purpose of the history and exam is to identify any disqualifying reasons for use of a respirator. These generally fall under the
following medical areas: No compromising heart, lung, or airway problems: no syncopal, seizure, or claustrophobic/behavioral disorders;
no significant musculoskeletal problems. Following medication inquiry, history shall be confined to shortness of breath, cough, wheeze,
external capacity, and brief past or present cardiopulmonary symptomatology. Additional history of syncopy, blackout, seizure,
claustrophobia, or past mask intolerance is relevant. Examination requires only a blood pressure, airway exam, hear-lungs, and general
assessment.
Item
Normal
Abnormal
Elaborate on abnormal items
Facial Configuration, Airway
Eardrum(s) Perforation(s)
Lungs
Heart
Other
BP:
Pulse:
Examiner
Weight:
Height:
Date
I have been informed that I should follow up with my personal physician in regard to the following medical problems:
Not Applicable
Hypertension
Diabetes
Lung Disorders
Other
I have been advised that I should notify my supervisor and coworkers of personal medical conditions as follows:
Not Applicable
Hypertension
Diabetes
Lung Disorders
Other
I have been advised to:
Not Applicable
Reduce my fat and caloric intake
Increase my aerobic exercise
Wear hearing protection when exposed to loud or excessive noise
Other
Signature
Date
Patient Name:
15 – RESPIRATORY HISTORY QUESTIONNAIRE
Quit Smoking
Date:
JANUARY 1, 2010
PAGE 4 OF 4