Part A. Section 1. (Mandatory) Every employee who has been selected to use any type of respirator (please print) mustprovide the following information.

Physical exertion while wearing a respirator

Mild

Moderate

Strenuous

Maximum time you wear a respirator in a single day:(hours)

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
(please select "yes" or "no").

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes No << Required

3.Have you ever had any of the following pulmonary or lung problems?

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

5. Have you ever had any of the following cardiovascular or heart problems?

6. Have you ever had any of the following cardiovascular or heart symptoms?

Frequent pain or tightness in your chest	Yes No	*
In the past two years, have you noticed your heart skipping or missing a beat	Yes No	*
Heartburn or symptoms that is not related to eating	Yes No	*
Any other symptoms that you think may be related to heart or circulation problems	Yes No	*

7. Do you currently take medication for any of the following problems?

Breathing or lung problems	Yes No	*
Heart trouble	Yes No	*
Blood Pressure	Yes No	*
Seizures(fits)	Yes No	*

8: Have you worn a respirator, including N95 and/or PAPR, before?

Yes No

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? Yes No << Required

10. Do you have facial hair that would interfere with the mask seal?
If not sure, please view the CDC guidelines https://www.cdc.gov/niosh/npptl/pdfs/facialhairwmask11282017-508.pdf Yes No << Required

To the best of my knowledge, the information I have provided is true and accurate

Date:

Seizures (fits)	Yes No	*
Diabetes (sugar disease)	Yes No	*
Allergic reactions that interfere with your breathing	Yes No	*
Claustrophobia (fear of closed-in places)	Yes No	*
Trouble smelling odors	Yes No	*

Asbestosis	Yes No	*
Asthma as an adult	Yes No	*
Chronic bronchitis	Yes No	*
Emphysema	Yes No	*
Pneumonia in the last month	Yes No	*
Tuberculosis	Yes No	*
Silicosis	Yes No	*
Lung cancer	Yes No	*
Any chest injuries or surgeries	Yes No	*
Any other lung problem that you've been told about	Yes No	*

Shortness of breath	Yes No	*
Shortness of breath with light activity	Yes No	*
Shortness of breath with strenuous activity	Yes No	*
Cough that produces thick sputum or blood	Yes No	*
Cough when you’re lying down or wakes you in early morning	Yes No	*
Wheezing	Yes No	*
Wheezing that interferes with your job	Yes No	*
Chest pain when you breathe deeply	Yes No	*
Any other symptoms that you think may be related to lung	Yes No	*

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 problem that you've been told about	Yes No	*

OSHA Respirator Medical Evaluation Questionnaire