Lodge Manufacturing Company
Appendix C to 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)
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 health care professional who will review it.
Part A. Section l. (Mandatory) The following information must be provided by every employee who has been selected touse any type of respirator (please print).
Can you read?
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Yes
No
Full Name
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First Name
Last Name
What is your age?
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What is your gender?
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Please Select
Male
Female
N/A
Your height is:
blanks
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ft
blank
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in.
Your weight is:
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Lbs
Your job title:
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Contact Number
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Format: (000) 000-0000.
The best time to phone you at this number is:
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Has your employer told you how to contact the health care professional who will review this questionnaire?
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Yes
No
Check the type of respirator you will use (you can check more than one category)
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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?
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Please Select
Yes
No
If you have worn a respirator, what kind?
Part A. Section 2. (Mandatory) Questions l through 9 below must be answered by every employee who has been selected to use any type of respirator (please circle “yes” or “no”).
Do you currently smoke tobacco, or have you smoked tobacco in the last month?
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Please Select
Yes
No
Have you ever had any of the following conditions? (Select all that apply.)
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Seizures (fits)
Trouble smelling odors
Diabetes (sugar disease)
Allergic reactions that interfere with your breathing
Claustrophobia (fear of closed-in places)
None of the above
Have you ever had any of the following pulmonary or lung problems? (Select all that apply.)
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Asbestosis
Pneumonia
Pneumothorax (collapsed lung)
Any other lung problem that you've been told about
Asthma
Tuberculosis
Lung Cancer
Any chest injuries or surgeries
Emphysema
Chronic bronchitis
Silicosis
None of the above
Do you currently have any of the following symptoms of pulmonary or lung illness? (Select all that apply.)
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Shortness of breath
Have to stop for breath when walking at your own pace on level ground
Coughing that produces phlegm (thick sputum)
Coughing up blood in the last month
Shortness of breath when walking fast on level ground or walking up a slight hill or incline
Shortness of breath when washing or dressing yourself
Coughing that wakes you early in the morning
Wheezing
Shortness of breath when walking with other people at an ordinary pace on level ground
Shortness of breath that interferes with your job
Coughing that occurs mostly when you are lying down
Wheezing that interferes with your job
Chest pain when you breathe deeply
Any other symptoms that you think may be related to lung problems
None of the Above
Have you ever had any of the following cardiovascular or heart problems? (Select all that apply.)
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Heart Attack
Stroke
Heart arrhythmia (heart beating irregularly)
Angina
High blood pressure
Heart Failure
Any other heart problem that you've been told about
None of the Above
Have you ever had any of the following cardiovascular or heart symptoms? (Select all that apply.)
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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
None of the above
Do you currently take medication for any of the following problems? (Select all that apply.)
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Breathing or lung problems
Heart trouble
Blood pressure
Seizures (fits)
None of the above
If you've used a respirator, have you ever had any of the following problems (Select all that apply.)
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Eye Irritation
Skin Allergies or rashes
Anxiety
General weakness or fatigue
Any other problem that interferes with your use of a respirator
I've never used a respirator.
Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire:
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Yes
No
Questions 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.
Have you ever lost vision in either eye (temporarily or permanently)?
Yes
No
Do you currently have any of the following visit problems? (Select all that apply.)
Wear contact-lenses
Wear Glasses
Color blind
Any other eye or vision problems
None of the above
Have you ever had an injury to your ears, including a broken ear drum?
Yes
No
Do you currently have any of the following hearing problems? (Select all that apply.)
Difficulty hearing
Wear a hearing aid
Any other hearing or ear problem?
None of the above
Have you ever had a back injury?
Yes
No
Do you currently have any of the following musculoskeletal problems? (Select all that apply.)
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 full moving your head up or down
Difficulty fully moving your head side to side
Difficulty squatting to the ground
Climbing a flight of stairs or a ladder carrying move than 25 lbs
Any other muscle or skeletal problem that interferes with using a respirator
None of the above
Signature
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Submit
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