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Home > Occupational Health > Respiratory Fit folder > OSHA Respirator Medical Evaluation Questionnaire (Mandatory) UVA-WorkMed

OSHA Respirator Medical Evaluation Questionnaire (Mandatory) UVA-WorkMed

To be filled out prior to a respiratory fit testing with UVA-WorkMed

Students: Please complete the following questionnaire. If you have questions, please call UVA-WorkMed at 434-243-0075. When you fill out the form, please click the "submit" button at the bottom of the page.  Note that the questions marked by a red square are mandatory.

Today's date
/ /   :
Your gender  


Check the type of respirator you will use:   (you can check more than one category)
Have you worn a respirator?  


Do you currently smoke tobacco, or have you smoked tobacco in the last month?  


Have you ever had seizures?  


Have you ever had diabetes?  


Have you ever had allergic reactions that interfere with your breathing?  


Have you ever had claustrophobia (fear of closed-in places)?  


Have you ever had trouble smelling odors?  


Have you ever had asbestosis?  


Have you ever had asthma?  


Have you ever had chronic bronchitis?  


Have you ever had emphysema?  


Have you ever had pneumonia?  


Have you ever had tuberculosis?  


Have you ever had silicosis?  


Have you ever had pneumothorax?  


Have you ever had lung cancer?  


Have you ever had broken ribs?  


Have you ever had any chest injuries or surgeries?  


Have you ever had any other lung problem that you've been told about?  


Do you currently have shortness of breath?  


Do you currently have shortness of breath when walking fast on level ground or walking up a slight hill or incline?  


Do you currently have shortness of breath when walking with other people at an ordinary pace on level ground?  


Do you currently have to stop for breath when walking at your own pace on level ground?  


Do you currently have shortness of breath when washing or dressing yourself?  


Do you currently have shortness of breath that interferes with your job?  


Do you currently have coughing that produces phlegm (thick sputum)?  


Do you currently have coughing that wakes you early in the morning?  


Do you currently have coughing that occurs mostly when you are lying down?  


Have you coughed up blood in the last month?  


Do you currently have wheezing?  


Do you currently have wheezing that interferes with your job?  


Do you currently have chest pain when you breathe deeply?  


Have you ever had a heart attack?  


Have you ever had a stroke?  


Have you ever had heart failure?  


Have you ever had swelling in your legs or feet (not caused by walking)?  


Have you ever had heart arrhythmia (heart beating irregularly)?  


Have you ever had high blood pressure?  


Have you ever had any other heart problem that you've been told about?  


Have you ever had frequent pain or tightness in your chest?  


Have you ever had pain or tightness in your chest during physical activity?  


Have you ever had 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?  


Do you currently take medication for breathing or lung problems?  


Do you currently take medication for heart trouble?  


Do you currently take medication for blood pressure?  


Do you currently take medication for seizures?  


If you've used a respirator, have you ever had eye irritation?


If you've used a respirator, have you ever had skin allergies or rashes?


If you've used a respirator, have you ever had anxiety?


If you've used a respirator, have you ever had general weakness or fatigue?


If you've used a respirator, have you ever had any other problem that interferes with your use of a respirator?


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