Kennesaw State University                                
Hazardous Waste Medical Questionnaire                Print This Page

Date:
Name: Sex: M F Age: Date of Birth:
Social Security Number: Height (in ft. and in.): Weight (in lbs.):
Marital Status: Single Married Divorced Widowed Separated
Ethnic Origin: White Asian Native American Black Hispanic Other
Employer:

Employer Address:

Street/PO Box:
City: State: Zip:

Job Title: Home Phone: Work Phone:
Best time to reach you by phone: morning noon evening
 
1. Check the type of respirator you will use (you can check more than one category):

    N, R, or P disposable respirator (filter-mask, non-cartridge type only)
    Other type (for example, half or full-faceplate type, powered-air purifying, supplied-air, self-contained breathing apparatus

2. Have you ever worn a respirator (check one)?

    If "yes" what type(s):

yes
no

3. Do you currently smoke tobacco, or have you smoked in the last month?
yes
no
4. Have you ever had any of the following conditions?
    a. Seizures (fits)
yes
no
    b. Diabetes (sugar disease)
yes
no
    c. Allergic reactions that interfere with your breathing
yes
no
    d. Claustrophobia (fear of closed-in places)
yes
no
    e. Trouble smelling odors
yes
no
5. Have you ever had any of the following pulmonary or lung illness?
    a. Asbestos
yes
no
    b. Asthma
yes
no
    c. Chronic bronchitis
yes
no
    d. Emphysema
yes
no
    e. Pneumonia
yes
no
    f. Tuberculosis
yes
no
    g. Silicosis
yes
no
    h. Pneumothorax (collapsed lung)
yes
no
    i. Lung cancer
yes
no
    j. Broken ribs
yes
no
    k. Any chest injuries/surgeries
yes
no
    l. Any other problem that you've been told about
yes
no

6. Do you currently have any of the following symptoms of pulmonary or lung illness?
    a. Shortness of breath
yes
no
    b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline
yes
no
    c. Shortness of breath when walking with other people
yes
no
    d. Have to stop for breath when walking with other people
yes
no
    e. Shortness of breath when washing or dressing yourself
yes
no
    f. Shortness of breath that interferes with your job
yes
no
    g. Coughing that produces phlegm (thick sputum)
yes
no
    h. Coughing that wakes you early in the morning
yes
no
    i. Coughing that occurs mostly when you are lying down
yes
no
    j. Coughing up blood in the last month
yes
no
    k. Wheezing
yes
no
    l. Wheezing that interferes with your job
yes
no
    m. Chest pain when you breathe deeply
yes
no
    n. Any other symptoms that you think may be related to lung problems
yes
no

7. Have you ever had any of the following cardiovascular or heart problems?
    a. Heart attack
yes
no
    b. Stroke
yes
no
    c. Angina
yes
no
    d. Heart failure
yes
no
    e. Swelling in your legs or feet (not caused by walking)
yes
no
    f. Heart dysrhythmia (heart beating irregularly)
yes
no
    g. High blood pressure
yes
no
    h. Any other heart problem that you've been told about
yes
no

8. Have you ever had any of the following cardiovascular or heart symptoms?
    a. Frequent pain or tightness in your chest
yes
no
    b. Pain or tightness in your chest during physical activity
yes
no
    c. Pain or tightness in your chest that interferes with your job
yes
no
    d. In the past two years, have you noticed your heart skipping or missing a beat
yes
no
    e. Heartburn or indigestion that is not related to eating
yes
no
    f. Any other symptoms that you think may be related to heart or circulation problems
yes
no
9. Do you currently take medication for any of the following problems?
    a. Breathing or lung problems
yes
no
    b. Heart trouble
yes
no
    c. Blood pressure
yes
no
    d. Seizures (fits)
yes
no

10. If you've used a respirator, have you ever had any of the following problems? (if you've never used a respirator, go to question 11)

    a. Eye irritation
yes
no
    b. Skin allergies or rashes
yes
no
    c. Anxiety
yes
no
    d. General weakness or fatigue
yes
no
    e. Any other problem that interferes with your use of a respirator
yes
no

11. Have you ever lost vision in either eye (temporarily or permanently)?
yes
no

12. Do you currently have any of the following vision problems?
    a. Wear contact lenses
yes
no
    b. Wear glasses
yes
no
    c. Color blind
yes
no
    d. Any other eye or vision problem
yes
no

13. Have you ever nad an injury to your ears, including a broken ear drum?
yes
no

14. Do you currently have any of the following hearing problems?
    a. Difficulty hearing
yes
no
    b. Wear a hearing aid
yes
no
    c. Any other hearing or ear problem
yes
no
15. Have you ever had a back injury?

 
yes
no

16. Do you currently have any of the following musculoskeletal problems?
    a. Weakness in any of your arms, hands, legs, or feet
yes
no
    b. Back pain
yes
no
    c. Difficulty fully moving your arms and legs
yes
no
    d. Pain or stiffness when you lean forward or backward at the waist
yes
no
    e. Difficulty fully moving your head up or down
yes
no
    f. Difficulty fully moving your head side to side
yes
no
    g. Difficulty bending at your knees
yes
no
    h. Difficulty squatting to the ground
yes
no
    i. Difficulty climbing a flight of stairs or a ladder carrying more than 25lbs.
yes
no
    j. Any other muscle or skeletal problem that interferes with using a respirator
yes
no

17. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals?

If "yes", name the chemicals if you know them:

 
yes
no

18. Have you ever worked with any of the materials, or under any of the conditions listed below?
    a. Asbestos
yes
no
    b. Silica (e.g., in sandblasting)
yes
no
    c. Tungsten/cobalt (e.g., grinding or welding this material)
yes
no
    d. Beryllium
yes
no
    e. Aluminum
yes
no
    f. Coal (for example, mining)
yes
no
    g. Iron
yes
no
    h. Tin
yes
no
    i. Dusty environments
yes
no

    j. Any other hazardous exposures

    if "yes" describe these exposures:

     
yes
no

19. List any second jobs or side businesses you have:

 

20. List your previous occupations:

 

21. List your current and previous hobbies:

 

22. Have you been in the military services?

If "yes" were you exposed to biological or chemical agents (either in training or combat)?

yes

yes

no

no

23. Have you ever worked on a HAZMAT team?
yes
no

24. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter)?

If "yes" name the medications if you know them.

 

 
yes
no

25. Will you be using any of the following items with your respirator(s)?
    a. HEPA Filters
yes
no
    b. Canisters (for example, gas masks)
yes
no
    c. Cartridges
yes
no

26. How often are you expected to use the respirator(s)? (check "yes" or "no" for all answers that apply to you)
    a. Escape only (no rescue)
yes
no
    b. Emergency rescue only
yes
no
    c. Less than 5 hours per week
yes
no
    d. Less than 2 hours per day
yes
no
    e. 2 to 4 hours per day
yes
no
    f. Over 4 hours per day
yes
no

27. Will you be working under hot conditions (temperature exceeding 77 degrees)
yes
no

28. Will you be working under humid conditions?
yes
no

29. Describe the work you'll be doing while you're using your respirator(s):