Silica Respirator Questionnaire Patient nameEmployer(Required)To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination. However, certain responses, or patterns of response, may lead the reviewer to request further information, or a medical examination, in order to reach a conclusion regarding the employee’s ability to safely use a respirator.To the employee, Patient ID:(Required)Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.Can you read?(Required) Yes No Part A. Section 1. (Mandatory) Every employee who has been selected to use any type of respirator must provide the following information.1. Sex(Required) Male Female 2. Your height: ft.(Required)2. Your height: in.(Required)3. Your weight: lbs(Required)4. Your job title:(Required)5. A phone number where you can be reached by the health care professional who reviews this questionnaire (include area code):(Required)The best time to call you at this number:(Required) Hours : Minutes AM PM AM/PM Has your employer told you how to contact the health care professional who will review this questionnaire?(Required) Yes No Check box(es) of the type of respirator you will use. (You can check more than one category).(Required) N, R or P disposable respirator (filter-mask, non-cartridge type only). Other type (for example, half- or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus). Have you worn a respirator?(Required) Yes No If “yes” what type(s)?(Required)Patient Name(Required)Part A. Section 2. (Mandatory) Every employee who has been selected to use any type of respirator must answer questions 1 through 9 below. 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?(Required) Yes No 2. Have you ever had any of the following conditions?(Required) Yes No Have you ever had any of the following conditions?(Required) Seizures (fits) Diabetes (sugar disease) Allergic reactions that interfere with your breathing Claustrophobia (fear of closed-in places) Trouble smelling odors 3. Have you ever had any of the following pulmonary or lung problems?(Required) Asbestosis Asthma Chronic bronchitis Emphysema Pneumonia Tuberculosis Silicosis Pneumothorax (collapsed lung) Lung cancer Broken ribs Any chest injuries or surgeries Any other lung problem that you’ve been told about 4. Do you currently have any of the following symptoms of pulmonary or lung illness?(Required) 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 or 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 phlegm (thick sputum) Coughing that wakes you early in the morning Coughing that occurs mostly when you are lying down Coughing up blood in the last month 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 5. Have you ever had any of the following cardiovascular or heart problems?(Required) 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 problem that you’ve been told about 6. Have you ever had any of the following cardiovascular or heart problems?(Required) 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 Heartburn or indigestion that is not related to eating Any other symptoms that you think may be related to heart or circulation problems 7. Do you currently take medication for any of the following problems?(Required) Breathing or lung problems Heart trouble Blood pressure Seizures (fits) 8. If you’ve used a respirator, have you ever had any of the following problems?(Required) Eye irritation Skin allergies or rashes Anxiety General weakness or fatigue Any other problem that interferes with your use of a respirator 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?(Required) Yes No Questions 10 to 15 must be answered by every employee who has been selected to use either a full-face piece 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)?(Required) Yes No 11. Do you currently have any of the following vision problems?(Required) Wear contact lenses Wear glasses Color blind Any other eye or vision problem 12. Have you ever had an injury to your ears, including a broken ear drum?(Required) Yes No 13. Do you currently have any of the following hearing problems?(Required) Difficulty hearing Wear a hearing aid Any other hearing or ear problem 14. Have you ever had a back injury?(Required) Yes No 15. Do you currently have any of the following musculoskeletal problems?(Required) 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 25 lbs Any other muscle or skeletal problem that interferes with using a respirator Respirator Physical Exam:HEIGHT:(Required)WEIGHT:(Required)PULSE:(Required)BLOOD PRESSURE (sitting):(Required)Physical ExamEyes(Required)Nose(Required)Oropharynx(Required)Teeth(Required)Outer Ear(Required)Ear Canal(Required)Beard/Mustache(Required)Neck(Required)Lung(Required)Hear(Required)Extremities(Required)TM’s(Required)Comments:(Required)Initial/Periodic Hazmat Exam Questionnaire1. Are you a member of a HAZ/MAT team?(Required) Yes No 2. Have you worn protective equipment (clothes, safety glasses, respirator, hearing protection)?(Required) Yes No 3. Have you participated in workplace medical monitoring (blood, urine, chest x-ray, respirator program?(Required) Yes No Have you ever experienced any of the following symptoms or conditions due to workplace exposure?1. Severe allergic reaction, difficulty breathing or swallowing(Required) Yes No 2. Heart pain, palpitations, heart muscle damage(Required) Yes No 3. Cough, shortness of breath, wheezing, asthma, lung damage, abnormal breathing tests or chest x-ray(Required) Yes No 4. Dizziness, fainting, blackouts, seizure, headaches, fatigue(Required) Yes No 5. Arm or leg weakness, numbness, pins/needles sensation(Required) Yes No 6. Abnormal liver blood tests, liver damage, hepatitis, weight loss, jaundice(Required) Yes No 7. Abdominal pain, stomach or intestinal problems, weight loss, blood in stool(Required) Yes No 8. Abnormal kidney blood or urine tests, kidney damage(Required) Yes No 9. Rash, skin cancer(Required) Yes No 10. Abnormal blood counts, anemia, swollen glands(Required) Yes No 11. Heat, cold illness, burns, frostbite(Required) Yes No 12. Difficulty with mood, memory, concentration(Required) Yes No Have or have had any of the following medical conditions?1. Hay fever, allergic rhinitis(Required) Yes No 2. Asthma, chronic bronchitis, COPD(Required) Yes No 3. Heart disease, congestive heart failure, hypertension, atrial fibrillation(Required) Yes No 4. Ulcers, Crohn’s disease, diverticulitis(Required) Yes No 5. Hepatitis, cirrhosis, liver disease, gallbladder disease(Required) Yes No 6. Stroke, seizures, depression, anxiety, dementia, Parkinson’s disease, multiple sclerosis(Required) Yes No 7. Leukemia, lymphoma, cancer(Required) Yes No 8. Another chronic/serious health condition(Required) Yes No 9. Any disability, physical limitation(Required) Yes No 10. Have you had any type of surgery(Required) Yes No 11. In previous jobs, did you have any occupational exposure to respirable silica:(Required) Yes No If yes, what was your job?(Required)12. What is your current level of occupational exposure to respirable silica?(Required)13. What is your current job?(Required)14. What is your anticipated level of future occupational exposure to respirable silica?(Required)15. Describe any personal protective equipment currently used, or to be used, to protect against respirable silica exposure:(Required)Have/had any of the following musculoskeletal conditions:1. Back injury, strain, herniated disc, recurring ache(Required) Yes No 2. Neck problems, neck pain, whiplash(Required) Yes No 3. Bursitis, tendonitis(Required) Yes No 4. Foot or ankle problems(Required) Yes No 5. Fractures(Required) Yes No 6. Hand, wrist, elbow problem(Required) Yes No 7. Knee or shoulder problems(Required) Yes No What year was your last diphtheria/tetanus booster?(Required)Have you completed the series of three Hepatitis B injections?(Required) Yes No List all medications you are currently taking:(Required)Previous EmploymentEmployer(Required)Job Title(Required)Dates Employed(Required)Employer(Required)Job Title(Required)Dates Employed(Required)Provider notes:(Required)Exposure history Please DESCRIBE any of the following exposures that may have occurred in the course of previous or current employment, or as a result of ongoing hobbies:
