Respirator Medical Evaluation Form
Please complete this form to help determine if you require further evaluation before using a respirator at work.
Full Name
*
First Name
Last Name
Job Title or Department
*
Workplace Location
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever had any breathing or lung problems (such as asthma, chronic bronchitis, or shortness of breath)?
*
Yes
No
Do you currently have any heart or circulation problems (such as high blood pressure, heart disease, or chest pain)?
*
Yes
No
Are you taking any medications that might affect your ability to safely wear a respirator?
*
Yes
No
Do you have any physical limitations (such as trouble seeing, hearing, or moving your head/neck) that could affect respirator use?
*
Yes
No
Have you experienced any discomfort or symptoms (such as dizziness, headaches, or anxiety) while wearing a respirator in the past?
*
Yes
No
Comments or additional information (optional)
Submit
Should be Empty: