1910.134: OSHA Respirator Medical Evaluation Questionnaire
Name:
SSN (last four digits):
Job Title:
Facility:
Sex:
Male
Female
Date of birth:
Height:
feet
inches
Weight:
lbs.
A phone number where you can be reached by the health care professional who reviews this questionnaire (include the area code):
The best time to phone you at this number:
Has your employer told you how to contact the health care professional who will review this questionnaire:
Yes
No
Check the type of respirator you will use (you can check more than one category):
N, R, or P disposable respirator (filter-mask, non-cartridge type only)
Other type (e.g. half-or-full-facepiece type, powered-air purifying, supplied-air, self contained breathing apparatus, etc.)
Have you worn a respirator:
Yes
No
The following questions must be answered by every employee who has been selected to use any time of respirator:
Do you currently smoke tobacco, or have you smoked tobacco in the last month:
Yes
No
Have you ever had any of the following conditions?
Seizures (fits):
Yes
No
Diabetes (sugar disease):
Yes
No
Allergic reactions that interfere with your breathing:
Yes
No
Claustrophobia (fear of closed in spaces):
Yes
No
Trouble smelling odors:
Yes
No
Have you ever had any of the following pulmonary or lung problems?
Asbestosis:
Yes
No
Asthma:
Yes
No
Bronchitis:
Yes
No
Emphysema:
Yes
No
Tuberculosis:
Yes
No
Silicosis:
Yes
No
Pneumothorax (collapsed lung):
Yes
No
Lung cancer:
Yes
No
Broken ribs:
Yes
No
Any chest injuries or surgeries:
Yes
No
Any other lung problems that you've been told about:
Yes
No
Do you currently have any of the following symptoms of pulmonary or lung illness?
Shortness of Breath:
Yes
No
Shortness of breath when walking fast on level ground or walking up a slight hill or incline:
Yes
No
Shortness of breath when walking with other people at an ordinary place on level ground:
Yes
No
Have to stop for breath when walking at your own pace on level ground
Yes
No
Shortness of breath when washing or dressing yourself:
Yes
No
Shortness of breath that interferes with your job:
Yes
No
Coughing that produces phlegm (thick sputum):
Yes
No
Coughing that wakes you early in the morning:
Yes
No
Coughing that occurs mostly when you are lying down:
Yes
No
Coughing up blood in the last month:
Yes
No
Wheezing:
Yes
No
Wheezing that interferes with your job:
Yes
No
Chest paint when you breathe deeply:
Yes
No
Any other symptoms that you think may be related to lung problems:
Yes
No
Have you ever had any of the following cardiovascular or heat problems?
Heart Attack:
Yes
No
Stroke:
Yes
No
Angina:
Yes
No
Heart Failure:
Yes
No
Swelling in your legs or feet (not caused by walking)
Yes
No
Heart arrhythmia (heart beating irregularly):
Yes
No
High blood pressure:
Yes
No
Any other heart problems that you've been told about:
Yes
No
Have you ever had any of the following cardiovascular or heart symptoms?
Frequent pain or tightness in your chest:
Yes
No
Pain or tightness in your chest:
Yes
No
Pain or tightness in your chest that interferes with your job:
Yes
No
In the past two years, have you noticed your heart skipping or missing a beat
Yes
No
In the past two years, have you noticed your heart skipping or missing a beat
Yes
No
Heartburn or indigestion that is not related to eating
Yes
No
Any other symptoms that you think may be related to heart or circulation problems:
Yes
No
Do you currently take medication for the following problems?
Breathing or lung problems:
Yes
No
Breathing or lung problems:
Yes
No
Heart trouble:
Yes
No
Blood pressure:
Yes
No
Seizures (fits):
Yes
No
Would you like to talk to the health care professional who will review this questionnaire about your answers:
Yes
No
Have you been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA):
Yes
No
Submit