Occupational Health Service
MEDICAL ASSESSMENT FOR WORKING WITH BREATHING APPARATUS
Complies with Respiratory Protective Equipment at Work – A Practical Guide, HSG 53 and COSHH (2002)
PERSONAL DETAILS
Name .………………………………………………………………. Date of Birth ……………………………………………
Department/Location .……………………………………………………………. ……………………………………………
Job Title .……………..…………………………………………….. Contact No …………………………………………….
TO BE COMPLETED BY EMPLOYEE
Have you ever had …
1.
2.
Yes
A condition affecting your heart or circulation, including any of the following: heart attack,
angina, valve disease, heart surgery, high blood pressure, pacemaker, other?
A condition causing any respiratory problems eg asthma, pneumonia, injury or operation to
chest?
3.
Diabetes?
4.
A condition affecting your nervous system including any of the following: epilepsy, fit, brain
surgery, stroke, head injury requiring hospital admission, blackouts, dizzy spells, problems, brain
tumour/haemorrhage, other?
A mental illness, including any of the following: claustrophobia, panic attacks, any other mental
health condition or admission to hospital for a mental health problem?
A condition affecting your eyesight including any of the following: cataract, glaucoma, eye
injury, double vision, other?
5.
6.
No
7.
A condition affecting your joints or mobility? eg sciatica, recurrent back pain
8.
Do you have difficulties with
9.
Do you have any allergies?
Neck movements
Lower limb movements
Upper limb movements
Lifting/carrying loads
10. Are you taking any prescribed medicines?
If “Yes”, give details ……………………………………………………………………………..
11. Do you drink alcohol? If “Yes”, how much in a typical week?....................................
1 unit = ½ pint beer. 1 unit = 1 small glass wine. 1 unit = 1 pub measure spirits.
12. Do you smoke/have you ever smoked? If yes how many? How long did you smoke? When did
you stop? ………………………………………………………………………………………….
13. Do you have any health concerns regarding this work?
If you have answered “Yes” to any of questions 1-12, please give brief details
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
DECLARATION
I have answered all questions to the best of my knowledge and belief. I agree to notify the Occupational Health
Service of any changes to my health/physical status?
Signature: ……………………………………………………………………. Date: ………………………………………….
Processed in accordance with the Data Protection Act 1998
Page 1
The University of Strathclyde is a charitable body, registered in Scotland, with registration number SC015263
MEDICAL ASSESSMENT
Respiratory Results
Measurement
FVC
FEV1
FEV1/FVC
Predicted
Actual
Audiometry Results
Is there wax in the external meatus?
Left:
Yes □ No□
Drum fully visible / partially visible / not seen
Right:
Yes □ No□
Drum fully visible / partially visible / not seen
Any abnormalities of the external meatus?
Yes □ No□
Is the tympanic membrane?
Left:
Normal / scarred / perforated / not seen
Right:
Normal / scarred / perforated / not seen
Any abnormalities of the tympanic membrane? Yes □ No□
Snellen’s Test Results
Left Eye
6/
Peripheral Vision
Right Eye
6/
Satisfactory 
Both Eyes
6/
Not Satisfactory 
Other Results
Height …………………...................... Weight............................................... BMI …………………………………
Blood Pressure …………………………………………….. Pulse…………………………………………………..
Urinalysis Protein …………………..................... Glucose ........................................... Blood …………………………………
1.
2.
Medically fit for working with Breathing Apparatus?
Referred to Occupational Health Physician?
Yes  No 
Yes  No 
Nurse Signature ………………………………………………………………………
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Date …………..……………………