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City of Seattle Respiratory Protection Questionnaire
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City of Seattle Respiratory Protection Questionnaire
"
*
" indicates required fields
Step
1
of
5
20%
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
*
FIRE
PARKS
FAS
CITY LIGHT
PUBLIC UTILITIES
DEPT. OF TRANSPORTATION
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
Male
Female
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
Tukwila
Seattle
Has your employer told you how to contact the health care provider who reviews this questionnaire?
Yes
No
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
No
2. Have you ever had any of the following condition?
A. Seizures (fits)
*
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)
*
Yes
No
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
*
Yes
No
C. Chronic Bronchitis
*
Yes
No
D. Emphysema
*
Yes
No
I. Are you under a doctor's care?
*
Yes
No
Asthma
II. Do you take medications for this problem?
*
Yes
No
Asthma
III. Have you had worsening of the problem in the last year requiring an urgent appointment, hospital admission or emergency room evaluation?
*
Yes
No
Asthma
I. Are you under a doctor's care?
*
Yes
No
Chronic Bronchitis
II. Do you take medications for this problem?
*
Yes
No
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
No
Chronic Bronchitis
I. Are you under a doctor's care?
*
Yes
No
Emphysema
II. Do you take medications for this problem?
*
Yes
No
Emphysema
III. Have you had worsening of the problem in the last year requiring an urgent appointment, hospital admission or emergency room evaluation?
*
Yes
No
Emphysema
E. Pneumonia
*
Yes
No
F. Tuberculosis
*
Yes
No
G. Silicosis
*
Yes
No
H. Pneumothorax (collapsed lung)
*
Yes
No
Have you completed treatment?
*
Yes
No
Pneumonia
I. Lung Cancer
*
Yes
No
J. Broken Ribs
*
Yes
No
K. Any chest injuries or surgeries?
*
Yes
No
L. Any other lung problem that you have been told about?
*
Yes
No
Do you have any residual pain or symptom?
*
Yes
No
Broken Ribs
Have you completed treatment?
*
Yes
No
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
No
B. Shortness of breath walking fast on level ground or walking up a hill or incline
*
Yes
No
C. Shortness of breath walking with other people at an ordinary pace on level ground
*
Yes
No
D. Have to stop for breath when walking at your own pace on level ground
*
Yes
No
E. Shortness of breath when bathing or dressing yourself
*
Yes
No
F. Shortness of breath that interferes with your job
*
Yes
No
G. Coughing that produces phlegm (thick sputum)
*
Yes
No
H. Coughing that wakes you early in the morning
*
Yes
No
I. Coughing that occurs mostly when you are lying down
*
Yes
No
J. Coughing up blood in the last month
*
Yes
No
K. Wheezing
*
Yes
No
L. Wheezing that interferes with your job
*
Yes
No
M. Chest pain when you breathe deeply
*
Yes
No
N. Any other symptoms that you think may be related to lung problems?
*
Yes
No
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
No
B. Stroke
*
Yes
No
C. Angina
*
Yes
No
D. Heart failure
*
Yes
No
E. Swelling in your legs and feet (not caused by walking)
*
Yes
No
F. Heart arrythmia (heart beating irregularly)
*
Yes
No
G. High blood pressure
*
Yes
No
H. Any other heart problem that you have been told about?
*
Yes
No
I. Are you under a doctor's care?
*
Yes
No
High blood pressure
II. Do you take medications for this problem?
*
Yes
No
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
No
High blood pressure
IV. Is your blood pressure under 140/90?
*
Yes
No
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
No
B. Pain or tightness in your chest during physical activity
*
Yes
No
C. Pain or tightness in your chest that interferes with your job?
*
Yes
No
D. In the past two years, have you noticed your heart skipping or missing a beat?
*
Yes
No
I. Are you under a doctor's care?
*
Yes
No
In the past two years, have you noticed your heart skipping or missing a beat
II. Do you take medications for this problem?
*
Yes
No
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
No
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
No
7. Do you currently take medication for any of the following problems?
A. Breathing or lung problems
*
Yes
No
B. Heart trouble
*
Yes
No
C. Blood pressure
*
Yes
No
D. Seizure (fits)
*
Yes
No
8. If you have used a respirator, have you ever had any of the following problems?
A. Eye Irritation
*
Yes
No
B. Skin allergies or rashes
*
Yes
No
C. Anxiety
*
Yes
No
D. General weakness or fatigue
*
Yes
No
E. Any other problem that interferes with your use of a resporator?
*
Yes
No
I. Was this a limited event that resolved within a day?
*
Yes
No
Eye Irritation
II. Did it interfere with your ability to continue to use the respiratory equipment at the time?
*
Yes
No
Eye Irritation
I. Was this a limited event that resolved within a day?
*
Yes
No
Skin allergies or rashes
II. Did it interfere with your ability to continue to use the respiratory equipment at the time?
*
Yes
No
Skin allergies or rashes
9. Would you like to talk to the health care professional who will review this questionnaire about your answers?
*
Yes
No
Part 3- Additional Questions for Users of Full-Facepiece Respirators or SCBAs Please check “Yes” or “No”
Full-Facepiece Respirators or SCBAs?
*
Yes
No
1. Have you ever lost vision in either eye?
*
Yes
No
2. Do you currently have any of these vision problems?
A. Need to wear contact lenses
*
Yes
No
B. Need to wear glasses
*
Yes
No
C. Color blindness
*
Yes
No
D. Any other eye or vision problem?
*
Yes
No
3. Have you ever had an injury to your ear, including a broken ear drum?
*
Yes
No
4. Do you currently have any of these hearing problems?
A. Difficulty hearing
*
Yes
No
B. Need to wear a hearing aid
*
Yes
No
C. Any other hearing or ear problem?
*
Yes
No
5. Have you ever had a back injury?
*
Yes
No
6. Do you currently have any of the following musculoskeletal problems?
A. Back pain
*
Yes
No
B. Difficulty fully moving your arms and legs
*
Yes
No
C. Pain or stiffness when you lean forward or backward at the waist
*
Yes
No
D. Pain or stiffness when you lean forward or backward at the waist
*
Yes
No
E. Difficulty fully moving your head side to side
*
Yes
No
F. Difficulty bending at your knees
*
Yes
No
G. Difficulty squatting to the ground
*
Yes
No
H. Difficulty climbing a flight of stairs or ladder carrying more than 25 lbs.
*
Yes
No
I. Any other muscle or skeletal problem not previously mentioned?
*
Yes
No
7. Do you now have, or have you ever had, weakness in any of your arms, hands, legs, or feet? *
*
Yes
No
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)
Name
This field is for validation purposes and should be left unchanged.
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