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Captures current symptoms, relevant medications, prior issues from respirator use, and optional additional questions for specific respirator categories, including vision and related concerns.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/appendix-c1-completefull-medical-evaluation-questionnaire-for-initial-fit-testing/307709/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/appendix-c1-completefull-medical-evaluation-questionnaire-for-initial-fit-testing/307709.png","ImageObject",442,249,{"name":42,"@type":43},"Jake","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",12,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who must complete this respirator medical evaluation questionnaire?","Question",{"text":63,"@type":64},"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.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which medical areas does the questionnaire cover?",{"text":68,"@type":64},"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.",{"name":70,"@type":61,"acceptedAnswer":71},"What additional questions are required for full facepiece respirators or SCBA?",{"text":72,"@type":64},"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.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},307709,1791179780,{"code":4,"msg":82,"data":83},"success",[84,89,93,98,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":26},962084928904,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","# Appendix C1-Complete/Full Medical Evaluation Questionnaire for Initial Fit Testing\n\nPart A.Section 1.(Mandatory)The following information must be provided by every employeewho has been selected to use any type of respirator.  \n1.Date                                Employee Workday Number:                                    \n2.  Name:                                                                                                            \n                      Title:                     \n3.Job Department:  \n4.Age:         \nMale  \nFemale  \n5.Sex  \nLbs.  \n6.Height:  \n        Ft.  \n       in 6.Weight:  \n          \n7.Your job title:                              \nDept.:                        \n8.Phone number where you can be reached by health care professional who reviews thisquestionnaire:                                The best time to phone you:___   ____  \n9.Has your employer provided you contact information for the health care professional who will review thisquestionnaire:Yes No  \n10.Check the type of respirator(s)you will use:  \na.          N,R or P Disposable respirator(filter-mask,non-cartridge type only)  \nb.        Other type:(half/full face piece type,powered-air purifying,supplied-air,SCBA):  \n11.Have you worn a respirator?Yes NoIf\"yes,\"what type(s).                        \nPart A.Section 2.(Mandatory)Questions 1 through 9 below must be answered by every employee who hasbeen selected to use any type of respirator.  \n1.Do you currently smoke tobacco,or smoked tobacco in the last month?Yes No  \n2.Have you ever had any of the following conditions?  \nYes No  \na.Sezures  \nYes  \nNo  \nb.Diabetes(sugar disease)  \nYes No  \nc.Allergic Reactions that interfere with your breathing:  \nYes No  \nd.Claustrophobia(fear of closed-in places)  \ne.Trouble smelling odors  \nYes  \nNo  \n3.Have you ever had any of the following pulmonary or lung problems?  \na.Asbestosis  \nYes   \nNo  \nb.Asthma  \nNo  \nYes  \nc.Chronic bronchitis  \nYes  \nNo  \nYes No  \nd.Emphysema  \nYes No  \ne.Pneumonia  \nf.Tuberculosis  \nYes No  \nYes No  \ng.Silicosis  \nYes No  \nh.Pneumothorax(collapsed lung)  \n1 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  \nLoyola University Medical Center |2160 S.First Ave.,Maywood,IL 60153|888-584-7888|loyolamedicine.org  \ni.Lung cancer  \nYes No  \nj.Broken Ribs  \nYes No  \nk.Any chest injuries or surgeries  \nYes No  \nAny other lung problem that you have been told about?  \nYes No  \n4.Do you currently have any of the following symptoms of pulmonary orlung illness?  \na.Shortness of breath:  \nYes No  \nb.Shortness of breath when walking fast on level ground or walking up a slight hill orincline:Yes No  \nc.Shortness of breath when walking with other people at an ordinary pace on levelground:  \nYes No  \nd.Have to stop for breath when walking at your own pace on level ground:  \nYes No  \ne.Shortness of breath when washing or dressing yourself:  \nYes No  \nShortness of breath that interferes with your job:  \nYes No  \nCoughing that produces phlegm (thick sputum):  \nYes No  \nf.Coughing that wakes you early in the morning:  \nYes No  \ng.Coughing that occurs mostly when you are lying down:  \nYes  \nNo  \nCoughing up blood in the last month:  \nYes No  \nh.Wheezing:  \nYes  \nNo  \ni.Wheezing that interferes with your job;  \nYes  \nNo  \nj.Chest pain when you breathe deeply:  \nYes No  \nk.Any other symptoms that you think may be related to lung problems?:  \nYes No  \n5.Have you ever had any of the following cardiovascular or heart problems?  \na.Heart attack:  \nYes No  \nb.Stroke:  \nYes No  \nC.Angina:  \nYes No  \nd.Heart failure:  \nYes No  \ne.Swelling in your legs or feet(not caused by walking):  \nYes  \nNo  \nf.Heart arrhythmia(heart beating irregularly):  \nYes No  \ng.High blood pressure:  \nYes No  \nh.Any other heart problem that you've been told about:  \nYes No  \n6.Have you ever had any of the following cardiovascular o","cbCaiaQTxzsXe0S0","https://ap.wps.com/l/cbCaiaQTxzsXe0S0","pdf",172663,6,"English","# Appendix C1-Complete/Full Medical Evaluation Questionnaire for Initial Fit Testing\n## Part A. Section 1 (Mandatory)\n## Part A. Section 2 (Mandatory)\n## Part A. Section 3 (Mandatory)","[{\"question\":\"Who must complete this respirator medical evaluation questionnaire?\",\"answer\":\"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.\"},{\"question\":\"Which medical areas does the questionnaire cover?\",\"answer\":\"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.\"},{\"question\":\"What additional questions are required for full facepiece respirators or SCBA?\",\"answer\":\"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.\"}]","Appendix C1-Complete/Full Medical Evaluation Questionnaire for Initial Fit Testing | PDF",1789853540]