City of Seattle Respiratory Protection Questionnaire

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To the Employee completing this form: Your confidentiality is protected in accordance with public law. Neither supervisors nor any other City employee are provided with your individual information. Note: Form must be signed and dated to be valid.

First Name*

Last Name*

Job Title

Address (Street)

Address (City)

Address (State)

Address (Zip Code)

Employee ID (if known)

Department*

Low Org No.

Email*

Part 1 – Employee Background Information – ALL Employees must complete this section

Date of Birth

MM slash DD slash YYYY

Age*

Sex

Height (feet)*

Height (inches)*

This value should be between 0 and 11.5.

Weight (lbs.)*

Please indicate below phone numbers where you can be reached by the health care provider who reviews this form and the best time to contact you using that phone.

Phone Number 1*

Phone Number 2

Phone Number 3

Phone Number 4

Best time to contact*

Phone Number 1

Best time to contact

Phone Number 2

Best time to contact

Phone Number 3

Best time to contact

Phone Number 4

The Work Clinic Location

Has your employer told you how to contact the health care provider who reviews this questionnaire?

Yes

Call The Work Clinic – Tukwila @ (206) 243-9675 or The Work Clinic – Seattle @ (206) 995-8868
You may be contacted by The Work Clinic if there are questions about your responses to this questionnaire.
Without complete information RESPIRATORY MEDICAL CLEARANCE may be delayed or may not be issued.

Part 2 – General Health Information I
ALL Employees must complete this part – Please check “Yes” or “No”

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

Yes

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

A. Seizures (fits)*

Yes

B. Diabetes (sugar disease)*

Yes

C. Allergic reactions that interfere with your breathing*

Yes

D. Claustrophobia (fear of closed-in places)*

Yes

E. Trouble smelling odors*

Yes

3. Have you ever had any of the following pulmonary or lung problems?

A. Asbestosis*

Yes

B. Asthma*

Yes

C. Chronic Bronchitis*

Yes

D. Emphysema*

Yes

I. Are you under a doctor's care?*

Yes

Asthma

II. Do you take medications for this problem?*

Yes

Asthma

III. Have you had worsening of the problem in the last year requiring an urgent appointment, hospital admission or emergency room evaluation?*

Yes

Asthma

I. Are you under a doctor's care?*

Yes

Chronic Bronchitis

II. Do you take medications for this problem?*

Yes

Chronic Bronchitis

III. Have you had worsening of the problem in the last year requiring an urgent appointment, hospital admission or emergency room evaluation?*

Yes

Chronic Bronchitis

I. Are you under a doctor's care?*

Yes

Emphysema

II. Do you take medications for this problem?*

Yes

Emphysema

III. Have you had worsening of the problem in the last year requiring an urgent appointment, hospital admission or emergency room evaluation?*

Yes

Emphysema

E. Pneumonia*

Yes

F. Tuberculosis*

Yes

G. Silicosis*

Yes

H. Pneumothorax (collapsed lung)*

Yes

Have you completed treatment?*

Yes

Pneumonia

I. Lung Cancer*

Yes

J. Broken Ribs*

Yes

K. Any chest injuries or surgeries?*

Yes

L. Any other lung problem that you have been told about?*

Yes

Do you have any residual pain or symptom?*

Yes

Broken Ribs

Have you completed treatment?*

Yes

Any chest injuries or surgeries

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

A. Shortness of breath*

Yes

B. Shortness of breath walking fast on level ground or walking up a hill or incline*

Yes

C. Shortness of breath walking with other people at an ordinary pace on level ground*

Yes

D. Have to stop for breath when walking at your own pace on level ground*

Yes

E. Shortness of breath when bathing or dressing yourself*

Yes

F. Shortness of breath that interferes with your job*

Yes

G. Coughing that produces phlegm (thick sputum)*

Yes

H. Coughing that wakes you early in the morning*

Yes

I. Coughing that occurs mostly when you are lying down*

Yes

J. Coughing up blood in the last month*

Yes

K. Wheezing*

Yes

L. Wheezing that interferes with your job*

Yes

M. Chest pain when you breathe deeply*

Yes

N. Any other symptoms that you think may be related to lung problems?*

Yes

Part 2 – General Health Information II ALL Employees must complete this part – Please check “Yes” or “No”

5. Have you ever had any of the following condition?

A. Heart attack*

Yes

B. Stroke*

Yes

C. Angina*

Yes

D. Heart failure*

Yes

E. Swelling in your legs and feet (not caused by walking)*

Yes

F. Heart arrythmia (heart beating irregularly)*

Yes

G. High blood pressure*

Yes

H. Any other heart problem that you have been told about?*

Yes

I. Are you under a doctor's care?*

Yes

High blood pressure

II. Do you take medications for this problem?*

Yes

High blood pressure

III. Have you had worsening of the problem in the last year requiring an urgent appointment, hospital admission, or emergency room evaluation?*

Yes

High blood pressure

IV. Is your blood pressure under 140/90?*

Yes

High blood pressure

6. Have you ever had any of the following cardiovascular or heart symptoms?

A. Frequent pain or tightness in your chest*

Yes

B. Pain or tightness in your chest during physical activity*

Yes

C. Pain or tightness in your chest that interferes with your job?*

Yes

D. In the past two years, have you noticed your heart skipping or missing a beat?*

Yes

I. Are you under a doctor's care?*

Yes

In the past two years, have you noticed your heart skipping or missing a beat

II. Do you take medications for this problem?*

Yes

In the past two years, have you noticed your heart skipping or missing a beat

III. Have you had worsening of the problem in the last year requiring an urgent appointment, hospital admission, or emergency room evaluation?*

Yes

In the past two years, have you noticed your heart skipping or missing a beat

IV. Has this been diagnosed as PVCs or PACs?*

Yes

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

A. Breathing or lung problems*

Yes

B. Heart trouble*

Yes

C. Blood pressure*

Yes

D. Seizure (fits)*

Yes

8. If you have used a respirator, have you ever had any of the following problems?

N/A (not applicable)*

Yes

A. Eye Irritation*

Yes

B. Skin allergies or rashes*

Yes

C. Anxiety*

Yes

D. General weakness or fatigue*

Yes

E. Any other problem that interferes with your use of a resporator?*

Yes

I. Was this a limited event that resolved within a day?*

Yes

Eye Irritation

II. Did it interfere with your ability to continue to use the respiratory equipment at the time?*

Yes

Eye Irritation

I. Was this a limited event that resolved within a day?*

Yes

Skin allergies or rashes

II. Did it interfere with your ability to continue to use the respiratory equipment at the time?*

Yes

Skin allergies or rashes

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

Yes

Part 3- Additional Questions for Users of Full-Facepiece Respirators or SCBAs Please check “Yes” or “No”

N/A (Not Applicable)*

Yes

N/A (Not Applicable) Part 3

1. Have you ever lost vision in either eye?*

Yes

2. Do you currently have any of these vision problems?

A. Need to wear contact lenses*

Yes

B. Need to wear glasses*

Yes

C. Color blindness*

Yes

D. Any other eye or vision problem?*

Yes

3. Have you ever had an injury to your ear, including a broken ear drum?*

Yes

4. Do you currently have any of these hearing problems?

A. Difficulty hearing*

Yes

B. Need to wear a hearing aid*

Yes

C. Any other hearing or ear problem?*

Yes

5. Have you ever had a back injury?*

Yes

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

A. Back pain*

Yes

B. Difficulty fully moving your arms and legs*

Yes

C. Pain or stiffness when you lean forward or backward at the waist*

Yes

D. Pain or stiffness when you lean forward or backward at the waist*

Yes

E. Difficulty fully moving your head side to side*

Yes

F. Difficulty bending at your knees*

Yes

G. Difficulty squatting to the ground*

Yes

H. Difficulty climbing a flight of stairs or ladder carrying more than 25 lbs.*

Yes

I. Any other muscle or skeletal problem not previously mentioned?*

Yes

7. Do you now have, or have you ever had, weakness in any of your arms, hands, legs, or feet? **

Yes

Part 4 – Please list all medications that you are currently taking

NOTE: For each of the medication please indicate the following: – Name of Medication – Dose (e.g. 250mg) – Frequency (e.g. once daily)

Signature*

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Comments

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City of Seattle Respiratory Protection Questionnaire

Part 1 – Employee Background Information – ALL Employees must complete this section

Part 2 – General Health Information I ALL Employees must complete this part – Please check “Yes” or “No”

Part 2 – General Health Information II ALL Employees must complete this part – Please check “Yes” or “No”

Part 3- Additional Questions for Users of Full-Facepiece Respirators or SCBAs Please check “Yes” or “No”

Part 4 – Please list all medications that you are currently taking

Part 2 – General Health Information I
ALL Employees must complete this part – Please check “Yes” or “No”