Respiratory Assessment Form
Employee's Health Surveillance Program
Employee
 Information
Name
First Name
Last Name
Birth Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Medical Conditions
1. Have you ever been diagnosed by a health professional about any of the following diseases?
Rows
Yes
No
Coronary heart disease
1
2
Angina
3
4
A heart attack
5
6
A stroke
7
8
High blood pressure or hypertension
9
10
Asthma
11
12
Emphysema
13
14
Chronic bronchitis
15
16
Rheumatoid arthritis
17
18
COPD (Chronic Obstructive Pulmonary Disease)
19
20
Respiratory Symptoms
2. Do you often cough?
Yes
No
How long do you have this cough? Specify in months or years.
3. Do you often cough up phlegm?
Yes
No
How long do you have phlegm? Specify in months or years.
4. Have you had wheezing or whistling in your chest in the last 12 months?
Yes
No
Choose one.
I have wheezing only when I have a cold.
I usually have wheezing apart from cold.
When you cough, does the wheezing gets cleared?
Yes
No
5. Have you had an asthma attack in the last 12 months?
Yes
No
How old were you when you had an asthma attack for the first time?
6. Is there any medication you are taking right now to help with your breathing?
Yes
No
Choose what you are taking.
Inhalers
Aerosols
Pills
7. Do you have shortness of breath when you act in a hurry?
Yes
No
Do you need to walk slower compared to people on your age due to short breathing?
Yes
No
How long do you have this shortness of breath? Specify in months or years.
Smoking History
8. Have you ever smoked cigarettes regularly?
Yes
No
Cigarettes per day
How old were you when you first started smoking cigarettes regularly?
Do you still smoke cigarettes?
Yes
No
9. Do you use any other tobacco or nicotine products that you inhale?
Yes
No
How often do you use them?
Sometimes
Usually
Every day
Submit
Should be Empty: