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3 D-14 3. Have you ever had any of the following pulmonary or lung problems? a. Asbestosis b. Asthma c. Chronic bronchitis d. Emphysema e. Pneumonia f. Tuberculosis g. Silicosis h. Pneumothorax (collapsed lung) i. Lung cancer j. Broken ribs k. Any chest injuries or surgeries l. Any other lung problem that you've been told about 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a. Shortness of breath b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline c. Shortness of breath when walking with other people at an ordinary pace on level ground d. Have to stop for breath when walking at your own pace on level ground e. Shortness of breath when washing or dressing yourself YES NO f. Shortness of breath that interferes with your job g. Coughing that produces phlegm (thick sputum) h. Coughing that wakes you early in the morning i. Coughing that occurs mostly when you are lying down j. Coughing up blood in the last month k. Wheezing l. Wheezing that interferes with your job m. Chest pain when you breathe deeply n. Any other symptoms that you think may be related to lung problems 5. Have you ever had any of the following cardiovascular or heart problems? a. Heart attack b. Stroke c. Angina d. Heart failure e. Swelling in your legs or feet (not caused by walking) f. Heart arrhythmia (heart beating irregularly) g. High blood pressure D-14 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 (please circle "yes" or "no"). YES NO 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? 2. Have you ever had any of the following conditions? a. Seizures b. Diabetes (sugar disease) c. Allergic reactions that interfere with your breathing d. Claustrophobia (fear of closed-in places) e. Trouble smelling odors 3. Have you ever had any of the following pulmonary or lung problems? a. Asbestosis b. Asthma c. Chronic bronchitis d. Emphysema e. Pneumonia f. Tuberculosis g. Silicosis h. Pneumothorax (collapsed lung) i. Lung cancer j. Broken ribs k. Any chest injuries or surgeries l. Any other lung problem that you've been told about 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a. Shortness of breath b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline c. Shortness of breath when walking with other people at an ordinary pace on level ground d. Have to stop for breath when walking at your own pace on level ground e. Shortness of breath when washing or dressing yourself