Skip to main content Skip to home page

Deaconess MyChart

Access Deaconess MyChart

Access Deaconess MyChart

Sign In
New User? Sign up now
Download For Your Mobile Device
  • Android
  • Apple
 

EFD Respirator Questionnaire

Gender:
Has your employer told you how to contact the health care professional who will review this questionnaire:
Have you worn a respirator:
Do you currently smoke tobacco, or have you smoked tobacco in the last month:
Seizures/Fits:
Diabetes (Sugar Disease):
Allergic reactions that interfere with your breathing:
Claustrophobia (fear of closed-in places):
Trouble smelling odors:
Asbestos:
Asthma:
Chronic Bronchitis:
Emphysema:
Pneumonia:
Tuberculosis:
Silicosis:
Pneumothorax (collapsed lung):
Lung Cancer:
Broken Rib:
Any chest injuries or surgeries:
Any other lung problem that you've been told about:
Shortness of Breath:
Shortness of breath when walking fast on level ground or walking up a slight hill or incline:
Shortness of breath when walking with other people at ordinary pace on level ground:
Have to stop for breath when walking at your own pace on level ground:
Shortness of breath when washing or dressing yourself:
Shortness of breath that interferes with your job:
Coughing that produces phlegm (thick sputum):
Coughing that wakes you early in morning:
Coughing that occurs mostly when you are lying down:
Coughing up blood in the last month:
Wheezing:
Wheezing that interferes with your job:
Chest pain when you breath deeply:
Any other symptoms that you think may be related to lung problems:
Heart Attack:
Stroke:
Angina:
Heart Failure:
Swelling in your legs or feet (not cause by walking):
Heart Arrhythmia (heart beating irregularly):
High blood pressure:
Any other heart problems that you've been told about:
Frequent pain or tightness in your chest:
Pain or tightness in your chest during activity:
Pain or tightness that interferes with your job:
In the past two years, have you noticed your heart skipping or missing a beat:
Heartburn or indigestion not related to eating:
Any other symptoms that may be related to heart or circulation problems:
Breathing or lung problems:
Heart Trouble:
Blood Pressure:
Seizures (fits):
Eye Irritation:
Skin allergies or rashes:
Anxiety:
General weakness or fatigue:
Any other problems that interfere with your used of a respirator:
Would you like to talk to a health care professional who will review this questionnaire:
Have you ever lost vision in either eye (temporarily or permanently):
Wear contact lenses:
Wear glasses:
Color Blind:
Any other eye or vision problem:
Have you ever had an injury to your ears, including a broken ear drum:
Difficulty Hearing:
Wear a hearing aid:
Any other hearing or ear problem:
Have you ever had a back injury:
Weakness in any of your arms, hands, legs, or feet:
Back Pain:
Difficulty moving your arms and legs:
Pain or stiffness when you lean forward or backward at the waist:
Difficulty fully moving your head and or down:
Difficulty fully moving your head side to side:
Difficulty fully bending at your knees:
Difficulty squatting to the ground:
Climbing a flight of stairs or a ladder carrying more than 25 lbs.:
Any other muscle or skeletal problem that interferes with using a respirator:
Top Back to top