Methodist Health : EMS-Mask Fit Questionnaire/Annual Health Screening

EMS-Mask Fit Questionnaire/Annual Health Screening
Respiratory Protection Questionnaire/Annual Health Screening
At Methodist Health 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. Per a new state requirement you will have an additional 7 questions as a part of your annual health screening. 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
	Part A. Section 2
	1. Do you currently smoke tobacco or have you smoked tobacco in the past month?	Yes No
	2. 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 youï¿½ve been told about
	3. 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
	4. 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
	5. 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 youï¿½ve 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
	6. 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
	If you answered "YES" to any of the questions 1-6: Do you feel that any condition you answered "YES" to above will prevent you from wearing a PAPR or N95 mask?	Yes No N/A
	Would you like to be evaluated by a healthcare professional before testing or wearing the PAPR or N95 mask?	Yes No
	Section 3
	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
	Do you use illegal drugs?	Yes No
	Are you pregnant?	Yes No
	Have you been hospitalized or had any surgeries in the past year? If yes, please explain.
	Have you had a work related injury the past year?	Yes No
	Have you ever had a needlestick/blood or body fluid exposure in the past year?	Yes No
	Are there any job duties you cannot perform due to physical or mental reasons?	Yes No
	Are there any other medical conditions you are being treated for that were not mentioned above? If yes, please explain.
	Would you like to talk to the health care professional that will review this questionnaire ?	Yes No
	Employee Electronic Signature
	Date

EMS-Mask Fit Questionnaire/Annual Health Screening

Respiratory Protection Questionnaire/Annual Health Screening

At Methodist Health 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.
Per a new state requirement you will have an additional 7 questions as a part of your annual health screening.
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?

Part A. Section 2

1. Do you currently smoke tobacco or have you smoked tobacco in the past month?

2. 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.

3. Have you ever had any of the following conditions?
Check all that apply.

4. 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

5. 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.

6. If you have used a respirator in the past, have you had any of the following problems?
Check all that apply.

If you answered "YES" to any of the questions 1-6: Do you feel that any condition you answered "YES" to above will prevent you from wearing a PAPR or N95 mask?

Would you like to be evaluated by a healthcare professional before testing or wearing the PAPR or N95 mask?

Section 3

Have you ever lost vision in either eye?
temporarily or permanently

Do you wear contact lenses

Do you wear glasses

Are you color blind

Any other eye or vision problems

Have you ever had an injury to your ears, including a broken ear drum

Do you have difficulty hearing

Do you wear a hearing aid

Any other hearing problems

Have you ever had a back injury

Do you have weakness in any of your arms, hands, legs, or feet

Do you have back pain

Do you have difficulty fully moving your arms and legs

Do you have difficulty fully moving your head up or down

Do you have difficulty fully moving your head side to side

Do you have difficulty bending at your knees

Do you have difficulty squatting to the ground

Do you have pain or stiffness when you lean forward or backward at the waist

Do you have difficulty climbing a flight of stairs or a ladder carrying more than 25 pounds

Do you have any other muscle or skeletal problems that interferes with using a respirator

Do you use illegal drugs?

Are you pregnant?

Have you been hospitalized or had any surgeries in the past year? If yes, please explain.

Have you had a work related injury the past year?

Have you ever had a needlestick/blood or body fluid exposure in the past year?

Are there any job duties you cannot perform due to physical or mental reasons?

Are there any other medical conditions you are being treated for that were not mentioned above? If yes, please explain.

Would you like to talk to the health care professional that will review this questionnaire ?

Employee Electronic Signature

Date