Issue link: http://iaqnet.uberflip.com/i/636984
4 D-15 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 h. Any other heart problem that you've been told about 6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in your chest b. Pain or tightness in your chest during physical activity c. Pain or tightness in your chest that interferes with your job d. In the past two years, have you noticed your heart skipping or missing a beat e. Heartburn or indigestion that is not related to eating f. Any other symptoms that you think may be related to heart or circulation problems 7. Do you currently take medication for any of the following problems? a. Breathing or lung problems b. Heart trouble 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 YES NO c. Blood pressure d. Seizures 8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check the following space and go to question 9.) a. Eye irritation b. Skin allergies or rashes c. Anxiety d. General weakness or fatigue e. Any other problem that interferes with your use of a respirator 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary. 10. Have you ever lost vision in either eye (temporarily or permanently)? 11. Do you currently have any of the following vision problems? a. Wear contact lenses b. Wear glasses c. Color blind d. Any other eye or vision problem 12. Have you ever had an injury to your ears, including a broken eardrum? 13. Do you currently have any of the following hearing problems? £