Appendix C1-Complete/Full Medical Evaluation Questionnaire for Initial Fit Testing

Sep 19, 2026

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Complete medical evaluation questionnaire for employees selected to use respirators, required for initial fit testing. Collects employee identity, work and contact details, demographics, and job title, then documents respirator type, prior respirator use, smoking history, and medical history affecting breathing, lungs, and cardiovascular function. Captures current symptoms, relevant medications, prior issues from respirator use, and optional additional questions for specific respirator categories, including vision and related concerns.

LanguageEnglish

CategoryForms

FormatPDF

Pages6

Reading Time2 min

AccessFree to download

Appendix C1-Complete/Full Medical Evaluation Questionnaire for Initial Fit Testing

Part A. Section 1 (Mandatory)

Part A. Section 2 (Mandatory)

Part A. Section 3 (Mandatory)

# Appendix C1-Complete/Full Medical Evaluation Questionnaire for Initial Fit Testing Part A.Section 1.(Mandatory)The following information must be provided by every employeewho has been selected to use any type of respirator. 1.Date Employee Workday Number: 2. Name: Title: 3.Job Department: 4.Age: Male Female 5.Sex Lbs. 6.Height: Ft. in 6.Weight: 7.Your job title: Dept.: 8.Phone number where you can be reached by health care professional who reviews thisquestionnaire: The best time to phone you:___ ____ 9.Has your employer provided you contact information for the health care professional who will review thisquestionnaire:Yes No 10.Check the type of respirator(s)you will use: a. N,R or P Disposable respirator(filter-mask,non-cartridge type only) b. Other type:(half/full face piece type,powered-air purifying,supplied-air,SCBA): 11.Have you worn a respirator?Yes NoIf"yes,"what type(s). Part A.Section 2.(Mandatory)Questions 1 through 9 below must be answered by every employee who hasbeen selected to use any type of respirator. 1.Do you currently smoke tobacco,or smoked tobacco in the last month?Yes No 2.Have you ever had any of the following conditions? Yes No a.Sezures Yes No b.Diabetes(sugar disease) Yes No c.Allergic Reactions that interfere with your breathing: Yes No d.Claustrophobia(fear of closed-in places) e.Trouble smelling odors Yes No 3.Have you ever had any of the following pulmonary or lung problems? a.Asbestosis Yes No b.Asthma No Yes c.Chronic bronchitis Yes No Yes No d.Emphysema Yes No e.Pneumonia f.Tuberculosis Yes No Yes No g.Silicosis Yes No h.Pneumothorax(collapsed lung) 1 of 8v.Trinity Health Insurance and Risk Management Services Procedure No.2.5,Effective Date February 15,2024We also treat the human spirit. A Member of Trinity Health Loyola University Medical Center |2160 S.First Ave.,Maywood,IL 60153|888-584-7888|loyolamedicine.org i.Lung cancer Yes No j.Broken Ribs Yes No k.Any chest injuries or surgeries Yes No Any other lung problem that you have been told about? Yes No 4.Do you currently have any of the following symptoms of pulmonary orlung illness? a.Shortness of breath: Yes No b.Shortness of breath when walking fast on level ground or walking up a slight hill orincline:Yes No c.Shortness of breath when walking with other people at an ordinary pace on levelground: Yes No d.Have to stop for breath when walking at your own pace on level ground: Yes No e.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 f.Coughing that wakes you early in the morning: Yes No g.Coughing that occurs mostly when you are lying down: Yes No Coughing up blood in the last month: Yes No h.Wheezing: Yes No i.Wheezing that interferes with your job; Yes No j.Chest pain when you breathe deeply: Yes No k.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? a.Heart attack: Yes No b.Stroke: Yes No C.Angina: Yes No d.Heart failure: Yes No e.Swelling in your legs or feet(not caused by walking): Yes No f.Heart arrhythmia(heart beating irregularly): Yes No g.High blood pressure: Yes No h.Any other heart problem that you've been told about: Yes No 6.Have you ever had any of the following cardiovascular o

FAQs

Who must complete this respirator medical evaluation questionnaire?

Every employee selected to use any type of respirator must provide the information in Part A, Section 1 and Part A, Section 2. Employees selected for full facepiece respirators or SCBA must also answer additional questions.

Which medical areas does the questionnaire cover?

It covers conditions and symptoms related to smoking, seizures, diabetes, breathing problems, lung disorders, cardiovascular or heart problems, and related symptoms. It also asks whether the employee takes medications for these issues.

What additional questions are required for full facepiece respirators or SCBA?

Questions 10–15 are required for employees selected to use a full facepiece respirator or SCBA, and the questionnaire includes vision-related items such as contact lenses, glasses, color blindness, and other vision problems.

Sep 19, 2026

Upload by Jake