Inglett & Stubbs Medical Evaluation Questionnaire

• Document No.

• Job Number/Site

• Conducted on

  Date

• Prepared by

• Employee

The following information must be provided by every employee selected to use any type of respirator.

• Name

• Age

• Male or Female

  Male

  Female

• Height (in feet & inches)

• Weight (in lbs.)

• Job Title

• Phone number where you can be reached by the healthcare professional who reviews this questionnaire (include area code)

• Best time to contact you at this number

  AM

  PM

• Has your employer told you how to contact the healthcare professional who will review this questionnaire?

  Yes

  No

• What type of respirator will you use? (you may select more than one)

  Select N, R, or P disposable respirator (filter mask, non-cartridge type only) Other type (example half or full face piece type, powered air purifying, supplied air, self-contained breathing apparatus)

  • N, R, or P disposable respirator (filter mask, non-cartridge type only)
  • Other type (example half or full face piece type, powered air purifying, supplied air, self-contained breathing apparatus)

• Have you worn a respirator?

  Yes

  No

• What type?

The following questions must be answered by every employee who has been selected to use any type of respirator.

• Do you currently smoke, 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?

• Asbestos

  Yes

  No

• Asthma

  Yes

  No

• Chronic bronchitis

  Yes

  No

• Emphysema

  Yes

  No

• Pneumonia

  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

• What?

• Any other lung problem that you've been told about?

  Yes

  No

• What?

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 pace 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 pain when you breathe deeply?

  Yes

  No

• Any other symptoms that you think may be related to lung problems?

  Yes

  No

• What?

Have you ever had any of the following cardiovascular or heart 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 problem that you've been told about?

  Yes

  No

• What?

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

• Breathing or lung problems?

  Yes

  No

• Heart trouble?

  Yes

  No

• Blood pressue?

  Yes

  No

• Seizures (fits)?

  Yes

  No

If you have used a respirator, have you ever had any of the following problems? If you have never used a respirator, please select N/A.

• Eye irritation?

  Yes

  No

  N/A

• Skin allergies or rashes?

  Yes

  No

  N/A

• Anxiety?

  Yes

  No

  N/A

• General weakness or fatigue?

  Yes

  No

  N/A

• Any other problem that interferes with your use of a respirator?

  Yes

  No

  N/A

• What?

• Would you like to talk to the healthcare professional who will review this questionnaire about your answers to the questionnaire?

  Yes

  No

• Have you ever lost vision in either eye (temporarily or permanently)?

  Yes

  No

Do you currently have any of the following vision problems?

• Wear contact lenses?

  Yes

  No

• Wear glasses?

  Yes

  No

• Color blind?

  Yes

  No

• Any other eye or vision problem?

  Yes

  No

• What?

• 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?

• Difficulty hearing?

  Yes

  No

• Wear a hearing aid?

  Yes

  No

• Any other hearing or ear problem?

  Yes

  No

• What?

• Have you ever had a back injury?

  Yes

  No

Do you currently have any of the following musculoskeletal problems?

• Weakness in any of your arms, hands, legs, or feet?

  Yes

  No

• Back pain?

  Yes

  No

• Difficulty fully moving your arms and legs?

  Yes

  No

• Pain or stiffness when you lean forward or backward at the waist?

  Yes

  No

• Difficulty fulling moving your head up or down?

  Yes

  No

• Difficulty fully moving your head side to side?

  Yes

  No

• Difficulty bending at your knees?

  Yes

  No

• Difficulty squatting to the ground?

  Yes

  No

• Difficulty climbing a flight of stairs or ladder carrying more than 25 lbs?

  Yes

  No

• Any other muscle or skeletal problem that interferes with using a respirator?

  Yes

  No

• What?

Employee Signature

• Signature

  Sign

• Date

  Date