OSHA Medical Questionnaire

* = required field
Part A. Section 1. (Mandatory)

The following information must be provided by every employee who has been selected to use any type of respirator.
Name Name * First Last
Job title *
Employee/Student ID *
Email *
Age *
Height *
Weight *
Phone Phone * - ### - ### ####

Phone number where you an be reached by the health care professional who will review this questionnaire.
Best time to call Best time to call * : HH MM AM/PM
Has your employer told you how to contact the health care professional who will review this questionnaire? *

Has your employer told you how to contact the health care professional who will review this questionnaire? Yes No
Type of respirator you will use *

Type of respirator you will use N, R, or P disposable respirator (filter-mask, non-cartridge type only) Other type (Examples: half-or full-facepiece type, powered-air purifying, supplier-air, self contained breathing apparatus)

Check all that apply.
Have you worn a respirator? *

Have you worn a respirator? Yes No
Part A. Section 2. (Mandatory)

Questions 1 - 9 must be answered by every employee who has been selected to use any type of respirator.
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? *

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes No
2. Have you ever had any of the following conditions?
2a. Seizures *

2a. Seizures Yes No
2b. Diabetes (sugar disease) *

2b. Diabetes (sugar disease) Yes No
2c. Allergic reactions that interfere with your breathing *

2c. Allergic reactions that interfere with your breathing Yes No
2d. Claustrophobia (fear of closed-in places) *

2d. Claustrophobia (fear of closed-in places) Yes No
2e. Trouble smelling odors *

2e. Trouble smelling odors Yes No
3. Have you ever had any of the following pulmonary or lung problems?
3a. Abestosis *

3a. Abestosis Yes No
3b. Asthma *

3b. Asthma Yes No
3c. Chronic bronchitis *

3c. Chronic bronchitis Yes No
3d. Emphysema *

3d. Emphysema Yes No
3e. Pneumonia *

3e. Pneumonia Yes No
3f. Tuberculosis *

3f. Tuberculosis Yes No
3g. Silicosis *

3g. Silicosis Yes No
3h. Pneumothorax (collapsed lung) *

3h. Pneumothorax (collapsed lung) Yes No
3i. Lung cancer *

3i. Lung cancer Yes No
3j. Broken ribs *

3j. Broken ribs Yes No
3k. Any chest injuries or surgeries *

3k. Any chest injuries or surgeries Yes No
3l. Any other lung problem that you've been told about *

3l. Any other lung problem that you've been told about Yes No
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
4a. Shortness of breath *

4a. Shortness of breath Yes No
4b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline *

4b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline Yes No
4c. Shortness of breath when walking with other people at an ordinary pace on level ground *

4c. Shortness of breath when walking with other people at an ordinary pace on level ground Yes No
4d. Have to stop for breath when walking at your own pace on level ground *

4d. Have to stop for breath when walking at your own pace on level ground Yes No
4e. Shortness of breath when washing or dressing yourself *

4e. Shortness of breath when washing or dressing yourself Yes No
4f. Shortness of breath that interferes with your job *

4f. Shortness of breath that interferes with your job Yes No
4g. Coughing that produces phlegm (thick sputum) *

4g. Coughing that produces phlegm (thick sputum) Yes No
4h. Coughing that wakes you early in the morning *

4h. Coughing that wakes you early in the morning Yes No
4i. Coughing that occurs mostly when you are lying down *

4i. Coughing that occurs mostly when you are lying down Yes No
4j. Coughing up blood in the last month *

4j. Coughing up blood in the last month Yes No
4k. Wheezing *

4k. Wheezing Yes No
4l. Wheezing that interferes with your job *

4l. Wheezing that interferes with your job Yes No
4m. Chest pain when you breathe deeply *

4m. Chest pain when you breathe deeply Yes No
4n. Any other symptoms that you think may be related to lung problems *

4n. Any other symptoms that you think may be related to lung problems Yes No
5. Have you ever had any of the following cardiovascular or heart problems?
5a. Heart attack *

5a. Heart attack Yes No
5b. Stroke *

5b. Stroke Yes No
5c. Angina *

5c. Angina Yes No
5d. Heart failure *

5d. Heart failure Yes No
5e. Swelling in your legs or feet (not caused by walking) *

5e. Swelling in your legs or feet (not caused by walking) Yes No
5f. Heart arrhythmia (heart beating irregularly) *

5f. Heart arrhythmia (heart beating irregularly) Yes No
5g. High blood pressure *

5g. High blood pressure Yes No
5h. Any other heart problem that you've been told about *

5h. Any other heart problem that you've been told about Yes No
6. Have you ever had any of the following cardiovascular or heart symptoms?
6a. Frequent pain or tightness in your chest *

6a. Frequent pain or tightness in your chest Yes No
6b. Pain or tightness in your chest during physical activity *

6b. Pain or tightness in your chest during physical activity Yes No
6c. Pain or tightness in your chest that interferes with your job *

6c. Pain or tightness in your chest that interferes with your job Yes No
6d. In the past two years, have you noticed your heart skipping or missing a beat *

6d. In the past two years, have you noticed your heart skipping or missing a beat Yes No
6e. Heartburn or indigestion that is not related to eating *

6e. Heartburn or indigestion that is not related to eating Yes No
6f. Any other symptoms that you think may be related to heart or circulation problems *

6f. 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?
7a. Breathing or lung problems *

7a. Breathing or lung problems Yes No
7b. Heart trouble *

7b. Heart trouble Yes No
7c. Blood pressure *

7c. Blood pressure Yes No
7d. Seizures *

7d. Seizures Yes No
8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check here * and go to question 9)
Yes No
8a. Eye irritation

8a. Eye irritation Yes No
8b. Skin allergies or rashes

8b. Skin allergies or rashes Yes No
8c. Anxiety

8c. Anxiety Yes No
8d. General weakness or fatigue

8d. General weakness or fatigue Yes No
8e. Any other problem that interferes with your use of a respirator

8e. Any other problem that interferes with your use of a respirator Yes No
9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? *

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? Yes No
Questions 10 to 15 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.
10. Have you ever lost vision in either eye (temporarily or permanently)?

10. Have you ever lost vision in either eye (temporarily or permanently)? Yes No
11. Do you currently have any of the following vision problems?
11a. Wear contact lenses

11a. Wear contact lenses Yes No
11b. Wear glasses

11b. Wear glasses Yes No
11c. Color blind

11c. Color blind Yes No
11d. Any other eye or vision problem

11d. Any other eye or vision problem Yes No
12. Have you ever had an injury to your ears, including a broken ear drum?

12. Have you ever had an injury to your ears, including a broken ear drum? Yes No
13. Do you currently have any of the following hearing problems?
13a. Difficulty hearing

13a. Difficulty hearing Yes No
13b. Wear a hearing aid

13b. Wear a hearing aid Yes No
13c. Any other hearing or ear problem

13c. Any other hearing or ear problem Yes No
14. Have you ever had a back injury?

14. Have you ever had a back injury? Yes No
15. Do you currently have any of the following musculoskeletal problems?
15a. Weakness in any of your arms, hands, legs, or feet

15a. Weakness in any of your arms, hands, legs, or feet Yes No
15b. Back pain

15b. Back pain Yes No
15c. Difficulty fully moving your arms and legs

15c. Difficulty fully moving your arms and legs Yes No
15d. Pain or stiffness when you lean forward or backward at the waist

15d. Pain or stiffness when you lean forward or backward at the waist Yes No
15e. Difficulty fully moving your head up or down

15e. Difficulty fully moving your head up or down Yes No
15f. Difficulty fully moving your head side to side

15f. Difficulty fully moving your head side to side Yes No
15g. Difficulty bending at your knees

15g. Difficulty bending at your knees Yes No
15h. Difficulty squatting to the ground

15h. Difficulty squatting to the ground Yes No
15i. Climbing a flight of stairs or a ladder carrying more than 25 lbs

15i. Climbing a flight of stairs or a ladder carrying more than 25 lbs Yes No
15j. Any other muscle or skeletal problem that interferes with using a respirator

15j. Any other muscle or skeletal problem that interferes with using a respirator Yes No
Part B

Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.
1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen? *

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen? Yes No
2. 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? *

2. 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? Yes No
3. Have you ever worked with any of the materials, or under any of the conditions, listed below?
3a. Asbestos *

3a. Asbestos Yes No
3b. Silica (e.g., in sandblasting) *

3b. Silica (e.g., in sandblasting) Yes No
3c. Tungsten/cobalt (e.g., grinding or welding this material) *

3c. Tungsten/cobalt (e.g., grinding or welding this material) Yes No
3d. Beryllium *

3d. Beryllium Yes No
3e. Aluminum *

3e. Aluminum Yes No
3f. Coal (for example, mining) *

3f. Coal (for example, mining) Yes No
3g. Iron *

3g. Iron Yes No
3h. Tin *

3h. Tin Yes No
3i. Dusty environments *

3i. Dusty environments Yes No
3j. Any other hazardous exposures *

3j. Any other hazardous exposures Yes No
4. List any second jobs or side businesses you have *

Please provide answer, "I don't know", or "Not applicable".
5. List your previous occupations *

Please provide answer, "I don't know", or "Not applicable".
6. List your current and previous hobbies *

Please provide answer, "I don't know", or "Not applicable".
7. Have you been in the military services? *

7. Have you been in the military services? Yes No
8. Have you ever worked on a HAZMAT team? *

8. Have you ever worked on a HAZMAT team? Yes No
9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications)

9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications) Yes No
10. Will you be using any of the following items with your respirator(s)?
10a. HEPA Filters *

10a. HEPA Filters Yes No
10b. Canisters (for example, gas masks) *

10b. Canisters (for example, gas masks) Yes No
10c. Cartridges *

10c. Cartridges Yes No
11. How often are you expected to use the respirator(s)?
11a. Escape only (no rescue) *

11a. Escape only (no rescue) Yes No
11b. Emergency rescue only *

11b. Emergency rescue only Yes No
11c. Less than 5 hours per week *

11c. Less than 5 hours per week Yes No
11d. Less than 2 hours per day *

11d. Less than 2 hours per day Yes No
11e. 2 to 4 hours per day *

11e. 2 to 4 hours per day Yes No
11f. Over 4 hours per day *

11f. Over 4 hours per day Yes No
12. During the period you are using the respirator(s), is your work effort:
12a. Light (less than 200 kcal per hour) *

12a. Light (less than 200 kcal per hour) Yes No

Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3lbs.) or controlling machines.
12b. Moderate (200 to 350 kcal per hour) *

12b. Moderate (200 to 350 kcal per hour) Yes No

Examples of moderate work effort are 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 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.
12c. Heavy (above 350 kcal per hour) *

12c. Heavy (above 350 kcal per hour) Yes No

Examples of heavy work are lifting a heavy load (about 50 lbs.) 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).
13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator? *

13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator? Yes No
14. Will you be working under hot conditions (temperature exceeding 77 deg. F)? *

14. Will you be working under hot conditions (temperature exceeding 77 deg. F)? Yes No
15. Will you be working under humid conditions? *

15. Will you be working under humid conditions? Yes No
16. Describe the work you'll be doing while you're using your respirator(s) *

Please provide answer, "I don't know", or "Not applicable".
17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases) *

Please provide answer, "I don't know", or "Not applicable".
18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s)
Name of the first toxic substance *

Please provide answer, "I don't know", or "Not applicable".
Duration of exposure per shift *

Please provide answer, "I don't know", or "Not applicable".
Estimated maximum exposure level per shift *

Please provide answer, "I don't know", or "Not applicable".
Name of the second toxic substance

Please provide answer, "I don't know", or "Not applicable".
2nd. Duration of 2nd exposure per shift

Please provide answer, "I don't know", or "Not applicable".
2nd. Estimated maximum exposure level per shift

Please provide answer, "I don't know", or "Not applicable".
Name of the third toxic substance

Please provide answer, "I don't know", or "Not applicable".
3rd. Estimated maximum exposure level per shift

Please provide answer, "I don't know", or "Not applicable".
3rd. Duration of exposure per shift

Please provide answer, "I don't know", or "Not applicable".
The name of any other toxic substances that you'll be exposed to while using your respirator *

Please provide answer, "I don't know", or "Not applicable".
19. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security) *

Please provide answer, "I don't know", or "Not applicable".

OSHA Medical Questionnaire

OSHA Medical Questionnaire

Part A. Section 1. (Mandatory)

Part A. Section 2. (Mandatory)

2. Have you ever had any of the following conditions?

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?

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

8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check here * and go to question 9)

Questions 10 to 15 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.

11. Do you currently have any of the following vision problems?

13. Do you currently have any of the following hearing problems?

15. Do you currently have any of the following musculoskeletal problems?

Part B

3. Have you ever worked with any of the materials, or under any of the conditions, listed below?

10. Will you be using any of the following items with your respirator(s)?

11. How often are you expected to use the respirator(s)?

12. During the period you are using the respirator(s), is your work effort:

18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s)