OSHA Medical Questionnaire
This form is required to be filled out and reviewed before respirator fit testing takes place and is taken form 29 CFR 1910.134. Please fill out to the best of your knowledge. If you have any questions please forward them to EHS@Crossoverhealth.com.
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Part A Section 1 (Mandatory)
Name
*
First Name
Last Name
Todays Date
*
-
Month
-
Day
Year
Date
Job Title
*
Please Select
Physician
Registered Nurse
Nurse Practitioner
LVN/LPN
Medical Assistant
Phlebotomist
Physician Assistant
Other
If you are not an MD/DO/NP/PA/RN/LVN/LPN/MA you need permission from the EHS team before submitting
Primary Clinic Location
*
Please Select
AMP Austin
AMP Gloucester
AMP Santa Clara
Apple Austin
Apple Elk Grove
DFA
Comcast Philly
Comcast 30 Rock
Crossover @ Duncanville
Crossover @ First Street
Crossover @ Garland
Crossover @ Grapevine
Crossover @ High Crest
Crossover @ Jeffersonville
Crossover @ Las Colinas
Crossover @ Maryvale
Crossover @ Mathilda
Crossover @ Midtown
Crossover @ Ridge Park
Crossover @ San Tomas
Crossover @ Shephersville
Crossover @ Shoreline
Crossover @ SOMA
Crossover @ Spring
Crossover @ Tempe
Crossover @ Tolleson
Facebook MPK281
Facebook MPK49
Frost
HP - Palo Alto
Micron
Microsoft
Telemundo
Visa
WD Great Oaks
WD Milpitas
Other
Supervisor (if known)
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number where you can be reached by the health care professional who reviews this questionnaire
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Have you ever worn a respirator or been fit tested?
*
Yes
No
If yes, what type?
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Part A. Section 2. (Mandatory)
Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator
Do you currently smoke tobacco, or have you smoked tobacco in the last month?
*
Yes
No
Have you ever had any of the following conditions?
*
Seizures
Diabetes
Allergic Reactions that interfere with your breathing
Claustrophobia (fear of closed-in places)
Trouble smelling odors
None of the above
Have you ever had any of the following pulmonary or lung problems?
*
Asbetosis
Asthma
Chronic Bronchitis
Emphysema
Pneumonia
Tuberculosis
Silicosis
Lung Cancer
Broken Ribs
Any chest injuries or surguries
Any other lung problems that you've been told about
None of the above
Do you currently have any of the following symptoms of pulmonary or lung illness?
*
Shortness of breath
Shortness of breath when walking fast on level ground or walking up a slight hill or incline
Shortness of breath when walking with other people at an ordinary pace on ground level
Have to stop for breath when walking at your own pace on ground level
Shortness of breath when washing or dressing yourself
Shortness of breath that interferes with your job
Coughing that produces phlegm (thick sputum)
Coughing that wakes you up in the early morning
Coughing that occurs mostly when you are laying down
Coughing up blood in the last month
Wheezing
Wheezing that interferes with you job
Chest pain when you breath deeply
Any other symptom that you think may be related to lung problems
None of the above
Have you ever had any of the following cardiovascular or heart problems?
*
Heart Attack
Stroke
Angina
Heart Failure
Swelling in your hands or feet (not caused by walking/standing)
Heart arrhythmia (heart beating irregularly)
High blood pressure
Any other heart problem you have been told about
None of the above
Have you ever had any of the following cardiovascular or heart symptoms?
*
Frequent pain or tightness in your chest
Pain or tightness in your chest during physical activity
Pain or tightness in your chest that interferes with your job
In the past two years, have you noticed your heart skipping or missing a beat
Heartburn or indigestion that is not related to eating
Any other symptoms that you think may be related to heart or circulation problems
None of the above
Do you currently take medication for any of the following problems?
*
Breathing or lung problems
Heart trouble
Blood pressure
Seizures
None of the above
If you've used a respirator before, have you ever had any of the following problems?
*
If you've never used a respirator check this box and go to the next question
Eye irritation
Skin allergies and rashes
Anxiety
General weakness or fatigue
Any other problem that interferes with your use of a respirator
None of the above
Would you like to talk to the healthcare professionals who will review this questionnaire about your answers to the questionnaire?
*
Yes
No
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Part A. Section 2. (Voluntary)
Questions 10 to 15 below are voluntary for employees who have been selected to use an N95 mask. You do not have to answer them.
Have you ever lost vision in either eye? (temporarily or permanently)
Yes
No
Do you currently have any of the following vision problems?
Wear contact lenses
Wear glasses
Color blind
Any other eye or vision problem
Have you ever had an injury to your ears, including a broken eardrum?
Yes
No
Do you currently have any of the following hearing problems?
Difficulty hearing
Wearing a hearing aid
Any other hearing or ear problem
Have you ever had a back injury?
Yes
No
Do you currently have any of the following musculoskeletal problems?
Weakness in any of your arms, legs or hands
Back pain
Difficulty fully moving your arms and legs
Pain or stiffness when you lean forward or backward at the waist
Difficulty fully moving your head side to side
Difficulty bending at the knees
Difficulty squatting to the ground
Climbing a flight of stairs or a ladder carrying more than 25lbs
Any other muscle or skeletal problem that interferes with using a respirator
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