Demographic Information and Health History

Your employer must allow you to answer this questionnaire during normal working hours or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, except for the employer's health care professional, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

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* 2. Your Name (First, MI, Last)

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* 3. Name of Employer

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* 4. Your Employee ID Number

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* 5. Date of Birth

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* 6. Gender

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* 7. Home Address (Optional)

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* 8. Home or Cell phone number (Optional)

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* 9. Work phone number

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* 10. Optimal time to call with inquiries (Morning, Afternoon, Evening)

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* 11. Employer Address or Work Location

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* 12. Job Title

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* 13. Name of Supervisor  (Optional)

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* 14. Your Height

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* 15. Your Weight

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* 17. What type(s) of respirator(s) have you used or are expecting to use

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* 19. Do you or have had any of the following conditions:

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* 20. Have you ever had any of the following pulmonary or lung problems

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* 21. Do you currently have any of the following symptoms of pulmonary or lung illness

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* 22. Have you ever had any of the following cardiovascular or heart problems

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* 23. Have you ever had any of the following cardiovascular or heart symptoms

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* 24. Do you currently take  medication for any of the following problems

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* 25. If you've used a respirator, have you ever had any of the following problems during or just after using the respirator

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* 28. Do you currently have any of the following vision problems

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* 30. Do you currently have any of the following hearing problems

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* 32. Do you currently have any of the following musculoskeletal problems

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* 34. Were you exposed to biological or chemical agents (Either in training or combat)

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* 37. Check those chemicals that you have worked with directly

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* 38. Have you worked in the following conditions in the past

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* 41. During the period you are using the respirator is your work effort:

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* 42. In which situation(s) are you expected to use the respirator

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* 43. What is the frequency of your respirator use

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* 44. Please provide an explanation for ANY yes answers on this entire questionnaire. Please refer back to your answers if necessary

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* 45. By typing my name here as an "Electronic Signature", I verify that the information provided in this medical history is true and complete to the best of my knowledge. I hereby give permission for a physical examination, if needed, to determine my fitness and suitability for safe respirator use.  I understand that this evaluation is designed to satisfy regulatory requirement and should not be considered to be a routine medical examination. Further - I agree to self-report to the medical unit any changes in my medical condition that might affect my ability to work safely in a respirator.

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