Respiratory Packet

Company

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Release of Medical Information

Name*

First Last

Date of Birth*

SS#*

Gender*

Race*

Employee ID*

Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone*

Text Message Consent*

I consent to receive updates via text message.

I do not consent to receive updates via text message.

Personal Email*

Your Results may be sent to you by email. Please provide an email for which you can receive your results. Most company firewalls will block outside e-mails, please provide a personal email address.

I hereby authorize ALLIANCE HEALTH RESOURCES Mobile Division, Ltd. to release all information obtained during medical surveillance and occupational related encounters to:

Company*

Company Contact Name*

Company Contact Address*

Street Address City State / Province / Region ZIP / Postal Code

This authorization shall expire one year after my employment with the company above ceases.
I may revoke this authorization in writing by contacting your office at the above address.
I understand that I may periodically be asked to update this Medical Release Form at the discretion of Alliance Health Resources Mobile Division, Ltd.
I understand that my authorization provided above means that the authorized organization can disclose,communicate or send my protected health information to the organization, entity or person identified above, including through the use of electronic means.

Signature*

Date*

OSHA Respirator Medical Evaluation

The following information must be provided by every employee who has been selected to use any type of respirator.

Can you read?*

Yes

No

Height*

Weight*

Job Title*

Has your employer told you how to contact the health care professional who will review this questionnaire?*

Yes

No

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-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus)

None

Have you worn a respirator before?*

Yes

No

What type(s)*

Have you ever had Seizures (fits)?*

Yes

No

Have you ever had Diabetes (sugar disease)?*

Yes

No

Have you ever had Allergic reactions that interfere with your breathing?*

Yes

No

Have you ever had Claustrophobia (fear of closed-in spaces)?*

Yes

No

Have you ever had trouble smelling odors?*

Yes

No

Have you ever had Asbestosis?*

Yes

No

Have you ever had Asthma?*

Yes

No

Have you ever had Chronic bronchitis?*

Yes

No

Have you ever had Emphysema?*

Yes

No

Have you ever had Pneumonia?*

Yes

No

Have you ever had Tuberculosis?*

Yes

No

Have you ever had Silicosis?*

Yes

No

Have you ever had Pneumothorax (collapsed lung)?*

Yes

No

Have you ever had Lung cancer?*

Yes

No

Have you ever had Broken ribs?*

Yes

No

Have you ever had any chest injuries or surgeries?*

Yes

No

Have you ever had any other lung problem that you've been told about?*

Yes

No

Do you have shortness of breath?*

Yes

No

Do you have shortness of breath when walking fast on level ground or walking up a slight hill or incline?*

Yes

No

Do you have shortness of breath when walking with other people at an ordinary pace on level ground?*

Yes

No

Do you have to stop for breath when walking at your own pace on ground level?*

Yes

No

Do you have shortness of breath when washing or dressing yourself?*

Yes

No

Do you have shortness of breath that interferes with your job?*

Yes

No

Do you have coughing that produces phlegm (thick sputum)?*

Yes

No

Do you have coughing that wakes you early in the morning?*

Yes

No

Coughing that occurs mostly when you are lying down*

Yes

No

Have you coughed up blood in the last month?*

Yes

No

Do you have wheezing?*

Yes

No

Do you have wheezing that interferes with your job?*

Yes

No

Do you have chest pain when you breathe deeply?*

Yes

No

Do you have any other symptoms that you think may be related to lung problems?*

Yes

No

Have you ever had a heart attack?*

Yes

No

Have you ever had a stroke?*

Yes

No

Have you ever had angina?*

Yes

No

Have you ever had heart failure?*

Yes

No

Have you ever had swelling in your legs or feet (not caused by walking)?*

Yes

No

Have you ever had heart arrhythmia (heart beating irregularly)?*

Yes

No

Have you ever had high blood pressure?*

Yes

No

Have you ever had any other heart problem that you've been told about?*

Yes

No

Have you ever had frequent pain or tightness in your chest?*

Yes

No

Have you ever had pain or tightness in your chest during physical activity?*

Yes

No

Have you ever had pain or tightness in your chest that interferes with your job?*

Yes

No

In the past two years, have you noticed your heart skipping or missing a beat?*

Yes

No

Have you ever had heartburn or indigestion that is not related to eating?*

Yes

No

Have you ever had any other symptoms that you think may be related to heart or circulation problems?*

Yes

No

Do you currently take medication for breathing or lung problems?*

Yes

No

Do you currently take medication for heart trouble?*

Yes

No

Do you currently take medication for blood pressure?*

Yes

No

Do you currently take medication for seizures (fits)?*

Yes

No

Have you ever had eye irritation?*

Yes

No

Have you ever had skin allergies or rashes?*

Yes

No

Have you ever had anxiety?*

Yes

No

Have you ever had general weakness or fatigue?*

Yes

No

Have you ever had any other problem that interferes with your use of a respirator?*

Yes

No

Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?*

Yes

No

Have you ever lost vision in either eye (temporarily or permanently)?*

Yes

No

Do you wear contact lenses?*

Yes

No

Do you wear glasses?*

Yes

No

Are you color blind?*

Yes

No

Do you have any other eye or vision problem?*

Yes

No

Have you ever had an injury to your ears, including a broken ear drum?*

Yes

No

Do you have difficulty hearing?*

Yes

No

Do you wear a hearing aid?*

Yes

No

Have you ever had a back injury?*

Yes

No

Do you have weakness in any of your arms, hands, legs, or feet?*

Yes

No

Do you have back pain?*

Yes

No

Do you have difficulty fully moving your arms and legs?*

Yes

No

Do you have pain or stiffness when you lean forward or backward at the waist?*

Yes

No

Do you have difficulty fully moving your head up or down?*

Yes

No

Do you have difficulty fully moving your head side to side?*

Yes

No

Do you have difficulty bending at your knees?*

Yes

No

Do you have difficulty squatting to the ground?*

Yes

No

Would you have difficulty climbing a flight of stairs or a ladder carrying more than 25 lbs?*

Yes

No

Do you have any other muscle or skeletal problem that interferes with using a respirator?*

Yes

No

In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen*

Yes

No

Do you have feelings of dizziness, shortness of breath, pounding in your chest or other symptoms when you're working under these conditions?*

Yes

No

At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (ex: gases, fumes, or dust) or have you come into skin contact with hazardous chemicals?*

Yes

No

List the names of the chemicals if you know them?*

Have you ever worked with any of the materials, or under any of the conditions listed below:*

List any second jobs or side business you have*

List your previous occupations*

List your current and previous hobbies*

Have you been in the military services?*

Yes

No

Have you been exposed to biological or chemical agents (either in training or combat)*

Yes

No

Have you ever worked on a HAZMAT team?*

Yes

No

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 medications)?*

Yes

No

Name the medications if you know them.*

Will you be using any of the following items with your respirator(s)?*

HEPA Filters

Canisters (for example, gas masks)

Cartridges

Other

How often are you expected to use the respirators (Check all that apply to you)*

During the period you are using the respirator(s) is your work effort:*

Light (less than 200kcal per hour)

Moderate (200 to 350 kcal per hour)

Heavy (above 350 kcal per hour)

Light: Sitting while writing, typing, light assembly work.

Medium: Nailing, Filing. Driving in urban traffic. Pushing wheelbarrow of heavy loads (100lb)

Heavy: Lifting loads of 50lbs or heavier from the floor to your waist/shoulders or carrying up stairs. Working on a loading dock/shoveling, standing while bricklaying or chipping castings.

How long does this period last during the average shift*

Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator*

Yes

No

Describe this protective clothing and/or equipment*

Will you be working under hot conditions (temperature exceeding 77 deg F)*

Yes

No

Will you be working under humid conditions:*

Yes

No

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

Describe any special or hazardous conditions you might encounter when you're using your respirator(s), (for example: confined spaces, life-threatening gases)*

Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirators(s):

Name of the toxic substance(s):

Estimated maximum exposure level per shift

Duration of exposure per shift:

Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example: rescue, security)*

Helpful Links

Release of Medical Information

OSHA Respirator Medical Evaluation

OSHA Respirator Medical Evaluation