2/24/2017 MethodistHospital:MaskFitQuestionnaire

MaskFitQuestionnaire

RespiratoryProtectionQuestionnaire
AtMethodistHospitalweutilizeMaxAirCAPR(ControlledAirPurifyingRespirators),afacemaskfor
airborneprecautionsinallareasexceptfortheORdisposablerespiratorymask,andEMS3MHalfFacepiece
respirator.AstaffmemberofEmployeeHealthServiceswillreviewthisquestionnaire.Ifyouhavequestions,
pleasefeelfreetocallusatext.7174.
Name
Age
Sex Male

Height
Weight
Haveyou Yes No
worna
respiratorin
thepast?
Doyousmoke Yes No
tobaccoor
haveyou
smoked
tobaccointhe
past?
Haveyouever Seizures(doyoucurrentlytakemedicationsforseizures)
hadanyofthe Diabetes(sugar)
following Allergicreactionsthatinterferewithyourbreathing
conditions?
Claustrophobia(fearofclosedinplaces)
Checkallthat
apply.
Troublesmellingodors

Haveyouever Asbestosis
hadanyofthe Asthma
following ChronicBronchitis
pulmonaryor
Emphysema
lungproblems
ordoyou Pneumonia
currentlytake Tuberculosis
medications Silicosis
foranyofthe Pneumonthorax
following LungCancer
problems? BrokenRibs
Checkallthat Anychestinjuriesorsurgeries
apply. Lungproblemthatyouvebeentoldabout
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2/24/2017 MethodistHospital:MaskFitQuestionnaire

Doyou Shortnessofbreath(SOB)
currentlyhave SOBwhenwalkingfastonlevelgroundoruphill
anyofthe SOBwhenwalkingonlevelgroundatordinarypace
following
Havetostopforbreathwhenwalkingatownpace
symptomsof
pulmonaryor SOBwhenwashingordressingself
lungillness? SOBthatinterfereswithyourjob
Checkallthat Coughingthatproducesphlegm(thicksputum)
apply. Coughingthatwakesyouearlyinthemorning
Coughingthatoccursmostlywhenyouarelyingdown
Coughingupbloodinthelastmonth
Wheezing
Wheezingthatinterfereswithyourjob
Chestpainwhenyoubreatheindeeply
Anyothersymptomsthatyoumayhavethatyouthinkarerelatedtolungproblems
Haveyouever Heartattack
hadanyofthe Stroke
following Angina
cardiovascular
Heartfailure
orheart
Heartpalpitations
problemsor
doyou Highbloodpressure
currentlytake Irregularheartbeat
any Legorfeetswelling
medications Frequentpainorchesttightness
forthe Painorchesttightnessduringphysicalactivity
following? Heartburnorindigestionthatisrelatedtoeating
Checkallthat Heartmissingabeatorskipping
apply.
Anyotherheartproblemthatyouvebeentoldabout
DoyouhaveseverefacialAcne?
Haveyouwornarespiratorinthepast?
Anyothersymptomsthatyouthinkmayberelatedtoheartorcirculationproblems
Ifyouhave Eyeirritationoreye
useda Skinallergiesorrashesfrommask
respiratorin Anxiety
thepast,have
Generalweaknessorfatigue
youhadanyof
Anyotherproblemthatinterfereswithyourrespiratoruse
thefollowing
problems?
Checkallthat
apply.

Haveyouever Yes No
lostvisionin
eithereye?
temporarilyor
permanently

Doyouwear Yes No
contactlenses
Doyouwear Yes No
glasses
Areyoucolor Yes No
blind

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2/24/2017 MethodistHospital:MaskFitQuestionnaire

Anyothereye Yes No
orvision
problems
Haveyouever Yes No
hadaninjury
toyourears,
includinga
brokenear
drum
Doyouhave Yes No
difficulty
hearing
Doyouweara Yes No
hearingaid
Anyother Yes No
hearing
problems
Haveyouever Yes No
hadaback
injury
Doyouhave Yes No
weaknessin
anyofyour
arms,hands,
legs,orfeet
Doyouhave Yes No
backpain
Doyouhave Yes No
difficultyfully
movingyour
armsandlegs
Doyouhave Yes No
difficultyfully
movingyour
headupor
down
Doyouhave Yes No
difficultyfully
movingyour
headsideto
side
Doyouhave Yes No
difficulty
bendingat
yourknees
Doyouhave Yes No
difficulty
squattingto
theground
Doyouhave Yes No

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2/24/2017 MethodistHospital:MaskFitQuestionnaire

painor
stiffnesswhen
youlean
forwardor
backwardat
thewaist
Doyouhave Yes No
difficulty
climbinga
flightofstairs
oraladder
carryingmore
than25
pounds
Doyouhave Yes No
anyother
muscleor
skeletal
problemsthat
interfereswith
usinga
respirator
Wouldyou Yes No
liketotalkto
thehealthcare
professional
thatwill
reviewthis
questionnaire
Employee
Electronic
Signature
DateofExam
Submit

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