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Methodist Hospital

Mask Fit Questionnaire

Respiratory Protection Questionnaire
At Methodist Hospital we utilize Max Air CAPR (Controlled Air Purifying Respirators), a face mask for airborne precautions in all areas except for the OR; disposable respiratory mask, and EMS; 3M Half-Facepiece respirator. A staff member of Employee Health Services will review this questionnaire. If you have questions, please feel free to call us at ext. 7174.
  Name
  Age
  Sex
  Height
  Weight
  Have you worn a respirator in the past? Yes     No    
  Do you smoke tobacco or have you smoked tobacco in the past? Yes     No    
  Have you ever had any of the following conditions?
Check all that apply.
Seizures (do you currently take medications for seizures)
Diabetes (sugar)
Allergic reactions that interfere with your breathing
Claustrophobia (fear of closed-in places)
Trouble smelling odors
  Have you ever had any of the following pulmonary or lung problems or do you currently take medications for any of the following problems?
Check all that apply.
Asbestosis
Asthma
Chronic Bronchitis
Emphysema
Pneumonia
Tuberculosis
Silicosis
Pneumonthorax
Lung Cancer
Broken Ribs
Any chest injuries or surgeries
Lung problem that you’ve been told about
  Do you currently have any of the following symptoms of pulmonary or lung illness?
Check all that apply.
Shortness of breath (SOB)
SOB when walking fast on level ground or up hill
SOB when walking on level ground at ordinary pace
Have to stop for breath when walking at own pace
SOB when washing or dressing self
SOB 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 in deeply
Any other symptoms that you may have that you think are related to lung problems
  Have you ever had any of the following cardiovascular or heart problems or do you currently take any medications for the following?
Check all that apply.
Heart attack
Stroke
Angina
Heart failure
Heart palpitations
High blood pressure
Irregular heart beat
Leg or feet swelling
Frequent pain or chest tightness
Pain or chest tightness during physical activity
Heartburn or indigestion that is related to eating
Heart missing a beat or skipping
Any other heart problem that you’ve been told about
Do you have severe facial Acne?
Have you worn a respirator in the past?
Any other symptoms that you think may be related to heart or circulation problems
  If you have used a respirator in the past, have you had any of the following problems?
Check all that apply.
Eye irritation or eye
Skin allergies or rashes from mask
Anxiety
General weakness or fatigue
Any other problem that interferes with your respirator use
  Have you ever lost vision in either eye?
temporarily or permanently
Yes     No    
  Do you wear contact lenses Yes     No    
  Do you wear glasses Yes     No    
  Are you color blind Yes     No    
  Any other eye or vision problems Yes     No    
  Have you ever had an injury to your ears, including a broken ear drum Yes     No    
  Do you have difficulty hearing Yes     No    
  Do you wear a hearing aid Yes     No    
  Any other hearing problems Yes     No    
  Have you ever had a back injury Yes     No    
  Do you have weakness in any of your arms, hands, legs, or feet Yes     No    
  Do you have back pain Yes     No    
  Do you have difficulty fully moving your arms and legs Yes     No    
  Do you have difficulty fully moving your head up or down Yes     No    
  Do you have difficulty fully moving your head side to side Yes     No    
  Do you have difficulty bending at your knees Yes     No    
  Do you have difficulty squatting to the ground Yes     No    
  Do you have pain or stiffness when you lean forward or backward at the waist Yes     No    
  Do you have difficulty climbing a flight of stairs or a ladder carrying more than 25 pounds Yes     No    
  Do you have any other muscle or skeletal problems that interferes with using a respirator Yes     No    
  Would you like to talk to the health care professional that will review this questionnaire Yes     No    
  Employee Electronic Signature
  Date of Exam