Respiratory Questionnaire

Transcription

1 Respiratory Questionnaire Date: Name: SS#: Sex: M F Height: Weight: DOB: Age: Employer: Department: Job Title: Phone # where you can be reached regarding this questionnaire (include area code): What is the best time to reach you at this number? Please explain any yes responses in the questionnaire. Check the type of respirator that you will use: N, R, or P disposable respirator (filter mask, non-cartridge type only) Other type (for example, half or full face piece OR powered air purifying supplied air, self-contained breathing apparatus) Have you ever worn a respirator? If YES, what type? Do you currently smoke tobacco, or have you smoked tobacco in the last month? Have you ever had any of the following conditions? Seizures Diabetes Allergic reactions that interfere with your breathing Claustrophobia Trouble smelling odors Have you ever had any of the following pulmonary or lung problems? Asbestosis Asthma Chronic bronchitis Emphysema Revision Date: 12/14 Page 1 of 9

2 Pneumonia Tuberculosis Silicosis Pneumothorax (collapsed lung) Any chest injuries or surgeries Any other lung problem that you ve been told about Do you currently have any of the following symptoms of pulmonary or lung illness? 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 thick sputum (phlegm) Coughing that wakes you early in the morning Coughing that occurs mostly when you are lying down Coughing up blood in the last month Revision Date: 12/14 Page 2 of 9

3 Do you currently have any of the following symptoms of pulmonary or lung illness? (continued) 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 Have you ever had any of the following cardiovascular or heart problems? 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 problems that you ve been told about Have you ever had any of the following cardiovascular or heart symptoms? 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 Revision Date: 12/14 Page 3 of 9

4 Heartburn or indigestion that is not related to eating Any other symptoms that you think may be related to heart or circulatory problems Do you currently take medication for any of the following problems? Breathing or lung problems Heart trouble Blood pressure Seizures If you ve used a respirator, have you ever had any of the following problems? (Skip this section if you have never used a respirator) Eye irritation Skin allergies or rashes Anxiety General weakness or fatigue Any other problem that interferes with your use of a respirator Do you currently have any of the following vision problems? History of loss of vision in either eye (temporarily or permanently) Wear contact lenses Wear glasses Color blind Eye injuries Any other eye or vision problems Revision Date: 12/14 Page 4 of 9

5 Do you currently have any of the following hearing problems? Difficulty hearing Wear a hearing aid History of ear injuries, including a broken ear drum Any other hearing or ear problem Do you currently have any of the following musculoskeletal problems? History of a back injury 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 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 25lbs. Any other muscle or skeletal problem that interferes with using a respirator YES NO In your present job, do you work at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen? Revision Date: 12/14 Page 5 of 9

6 IF YES, do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you are working under these conditions? YES NO At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g. gases, fumes, or dust), or have you come into skin contact with hazardous chemicals? IF YES, name the chemical(s) if you know them: Have you ever worked with any of the materials, or under any of the conditions, listed below: Asbestos Silica (e.g., grinding or welding this material) Tungsten/cobalt (e.g., grinding or welding this material) Beryllium Aluminum Coal (for example, mining) Iron Tin Dusty environments Any other hazardous exposures IF YES to any of the above, please describe these exposures: List any second jobs or side business you have: List your previous occupations: Revision Date: 12/14 Page 6 of 9

7 List your current and previous hobbies: Have you been in the military services? IF YES, were you exposed to chemical or biological agents (either in training or duty/combat) Other than medications for breathing and/or lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this evaluation, are you taking any other medications for any reason (including over-the-counter medications)? IF YES, name the medication(s) if you know them: Will you be using any of the following items with your respirator(s)? HEPA filters Canisters (for example, gas masks) Cartridges How often are you expected to use the respirator(s)? Escape only (no rescue) Emergency rescue only Less than 5 hours per week Less than 2 hours per day 2 to 4 hours per day Over 4 hours per day During the period you are using the respirator, is your work effort: Light (less than 200 kcal per hour), i.e. sitting while writing, typing, drafting, or performing light assembly work; standing while operating a drill press or controlling machines IF YES, how long does this period last during the average shift? hrs. mins. Moderate ( kcal per hour), i.e. sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35lbs.) at trunk level; walking on a level surface about 2mph or down a 5-degree grade about 3mph; pushing a wheelbarrow with a heavy load (about 100lbs.) on a level surface IF YES, how long does this period last during the average shift? hrs. mins. Revision Date: 12/14 Page 7 of 9

8 Heavy (above 350 kcal per hour), i.e. lifting a heavy load (about 50lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2mph; climbing stairs with a heavy load (about 50lbs.) IF YES, how long does this period last during the average shift? hrs. mins. Will you be wearing protective clothing and/or equipment when you are using your respirator? IF YES, describe this protective clothing and/or equipment: Will you be working under hot conditions (temperature exceeding 77 F)? Will you be working in humid conditions? Describe the work you ll be doing while you use your respirator: Describe any special or hazardous conditions you might encounter when using your respirator (i.e. confined spaces, lifethreatening gases) Describe any special responsibilities you will have while using your respirator that may affect the safety and well-being of others (i.e., rescue, security): Provide the following information, if you know it, for each toxic substance that you will be exposed to when you are using your respirator: Name of the first toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: Name of the second toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: Name of the third toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: Name any other toxic substances that you may will be exposed to while using your respirator: Revision Date: 12/14 Page 8 of 9

9 YES NO Would you like to talk to the health care professional who will be reviewing this questionnaire about your responses to these questions? If yes, please explain in this area: Complete the following questions ONLY if you have been previously fitted for a respirator Have you had any significant dental work since your last fit test? Do you currently have a beard or mustache? Have you gained or lost a significant amount of weight since your last fit test? Do you have any problems with the fit of your mask? Would you like to have a re-fit of your respiratory mask? Do you have any questions regarding the fit of your mask? Please be sure that any YES responses in the questionnaire are explained. Patient Printed Name: Date; Time: Patient Signature Revision Date: 12/14 Page 9 of 9