Skip to content
Occupational Medicine Services
for Employers
Services
Forms
About Us
Blog
Contact Us
Services
Forms
About Us
Blog
Contact Us
OSHA Respirator Medical Evaluation Questionnaire
Part A Section 1
(Mandatory)
The following information must be provided by every employee who has been selected to use any type of respirator.
Name
(Required)
Date of Birth
(Required)
Your age (to nearest year)
(Required)
Sex
(Required)
Female
Male
Your height (in ft. in.)
(Required)
Your weight (lbs)
(Required)
Your job title
(Required)
A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code)
(Required)
The best time to phone you at this number
(Required)
Has your employer told you how to contact the health care professional who will review this questionnaire
(Required)
Yes
No
Check the type of respirator you will use
(Required)
N, R, or P disposable respirator (filter-mask, non-cartridge type only)
Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus)
Have you worn a respirator?
(Required)
Yes
No
If “yes,” what type(s)
(Required)
Part A. Section 2
(Mandatory)
Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator.
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?
(Required)
Yes
No
2. Have you ever had any of the following conditions?
(Required)
Seizures
Diabetes (sugar disease)
Allergic reactions that interfere with your breathing
Claustrophobia (fear of closed-in places)
Trouble smelling odors
No. None of the above
3. Have you ever had any of the following pulmonary or lung problems?
(Required)
Asbestosis
Asthma
Chronic bronchitis
Emphysema
Pneumonia
Tuberculosis
Silicosis
Pneumothorax (collapsed lung)
Lung cancer
Broken ribs
Any chest injuries or surgeries
Any other lung problem that you've been told about
No. None of the above
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
(Required)
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
Shortness of breath that interferes with your job
Coughing that produces phlegm (thick sputum)
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 breathe deeply
Any other symptoms that you think may be related to lung problems
No. None of the above
5. Have you ever had any of the following cardiovascular or heart problems?
(Required)
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've been told about
No. None of the above
6. Have you ever had any of the following cardiovascular or heart symptoms?
(Required)
Frequent pain or tightness in your chest
Pain or tightness in your chest during physical activity
Pain or tightness in your chest that interferes with your job
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
No. None of the above
7. Do you currently take medication for any of the following problems?
(Required)
Breathing or lung problems
Heart trouble
Blood pressure
Seizures
No. None of the above
8. Have you ever used a respirator?
(Required)
Yes
No
If you've used a respirator, have you ever had any of the following problems?
(Required)
Eye irritation
Skin allergies or rashes
Anxiety
General weakness or fatigue
Any other problem that interferes with your use of a respirator
No. None of the above
9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?
(Required)
Yes
No
Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.
10. Have you ever lost vision in either eye (temporarily or permanently)?
Yes
No
11. Do you currently have any of the following vision problems?
Wear contact lenses
Wear glasses
Color blind
Any other eye or vision problem
No. None of the above
12. Have you ever had an injury to your ears, including a broken eardrum?
Yes
No
13. Do you currently have any of the following hearing problems?
Difficulty hearing
Wear a hearing aid
Any other hearing or ear problem
No. None of the above
14. Have you ever had a back injury?
Yes
No
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 and 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
Climbing a flight of stairs or a ladder carrying more than 25 lbs
Any other muscle or skeletal problem that interferes with using a respirator
No. None of the above
Δ
Go to Top
