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Evaluation Survey Form
Section 1: General Information (Mandatory)
Full Name
*
*
Employee ID #
*
Company
*
*
Facility Name
*
*
Age
*
*
Sex
*
Male
Female
Prefer not to say
Height
*
*
Weight
*
*
*
Phone Number
*
*
Contact Time
*
Day
Evening
Position
*
Apprentice
Body Tech
Buffer
Counter CSR (Respirator)
Mechanic
Painter
Tech Rep
EV Tech
Spray Tech
Respirator
*
Dust Mask
Cartridge (Half Face)
Cartridge (Full Face)
PAPR
Fresh Air Line
Never Used A Respirator
Respirator Duration
*
8 Hours per day
4 Hours per day
1 Hour per day
Few occasions during the week
Rarely
Respirator Work Effort
*
Light (desk job)
Moderate (assembly line)
Heavy (construction)
Strenuous (fire fighting)
Temperature
*
Above 100 degrees
85-99 degrees
70-84 degrees
Below 70 degrees
Humidity
*
Above 100% humidity
85-99% humidity
70-84% humidity
Below 70% humidity
Section 2: Medical Survey (Mandatory)
1 - Do you currently smoke tobacco?
*
1 - Do you currently smoke tobacco?
No
1 - Do you currently smoke tobacco?
Yes
2 - Have you smoked tobacco in the last month?
*
2 - Have you smoked tobacco in the last month?
No
2 - Have you smoked tobacco in the last month?
Yes
Have you ever had any of the following conditions?
3 - Seizures (fits)
*
3 - Seizures (fits)
No
3 - Seizures (fits)
Yes
How often do you have a seizure?
*
Rarely
Occasionally
Frequently
Every Day
Select
When was your last seizure?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Are you seeing a doctor for your seizures?
*
Are you seeing a doctor for your seizures?
No
Are you seeing a doctor for your seizures?
Yes
Are you taking any medication to treat them?
*
Are you taking any medication to treat them?
No
Are you taking any medication to treat them?
Yes
Have you ever had a seizure at work?
*
Have you ever had a seizure at work?
No
Have you ever had a seizure at work?
Yes
Do the seizures interfere with wearing the respirator mask?
*
Do the seizures interfere with wearing the respirator mask?
No
Do the seizures interfere with wearing the respirator mask?
Yes
4 - Diabetes (sugar disease)
*
4 - Diabetes (sugar disease)
No
4 - Diabetes (sugar disease)
Yes
What type of Diabetes do you have?
*
Type 1
Type 2
Gestational
Unknown
Select
Do you monitor your blood glucose levels at home?
*
Do you monitor your blood glucose levels at home?
No
Do you monitor your blood glucose levels at home?
Yes
Are your glucose levels well controlled with your current regimen?
*
Are your glucose levels well controlled with your current regimen?
No
Are your glucose levels well controlled with your current regimen?
Yes
Are you insulin dependent?
*
Are you insulin dependent?
No
Are you insulin dependent?
Yes
Does the Diabetes interfere with wearing the respirator mask?
*
Does the Diabetes interfere with wearing the respirator mask?
No
Does the Diabetes interfere with wearing the respirator mask?
Yes
5 - Allergic reactions causing breath interference
*
5 - Allergic reactions causing breath interference
No
5 - Allergic reactions causing breath interference
Yes
Describe the nature of your allergies (seasonal, food, animals).
*
Are you currently on medication for allergies?
*
Are you currently on medication for allergies?
No
Are you currently on medication for allergies?
Yes
Do you carry an Epi Pen?
*
Do you carry an Epi Pen?
No
Do you carry an Epi Pen?
Yes
Do you have any recurring complications from allergies?
*
Do you have any recurring complications from allergies?
No
Do you have any recurring complications from allergies?
Yes
Do your allergies interfere with wearing the respirator mask?
*
Do your allergies interfere with wearing the respirator mask?
No
Do your allergies interfere with wearing the respirator mask?
Yes
6 - Claustrophobia (fear of closed-in places)
*
6 - Claustrophobia (fear of closed-in places)
No
6 - Claustrophobia (fear of closed-in places)
Yes
How often do you feel claustrophobic when wearing the respirator mask?
*
Rarely
Occasionally
Frequently
Every Day
Select
7 - Trouble smelling odors
*
7 - Trouble smelling odors
No
7 - Trouble smelling odors
Yes
How often do you have trouble smelling odors?
*
Rarely
Occasionally
Frequently
Every Day
Select
Have you ever had trouble smelling odors at work?
*
Have you ever had trouble smelling odors at work?
No
Have you ever had trouble smelling odors at work?
Yes
Does your trouble smelling odors interfere with wearing a respirator mask?
*
Does your trouble smelling odors interfere with wearing a respirator mask?
No
Does your trouble smelling odors interfere with wearing a respirator mask?
Yes
Have you ever had any of the following pulmonary or lung problems?
8 - Asbestosis
*
8 - Asbestosis
No
8 - Asbestosis
Yes
Are you currently diagnosed with Asbestosis?
*
Are you currently diagnosed with Asbestosis?
No
Are you currently diagnosed with Asbestosis?
Yes
Are you currently on medication for Asbestosis?
*
Are you currently on medication for Asbestosis?
No
Are you currently on medication for Asbestosis?
Yes
Do you have recurring complications from Asbestosis?
*
Do you have recurring complications from Asbestosis?
No
Do you have recurring complications from Asbestosis?
Yes
Does the Asbestosis interfere with wearing a respirator mask?
*
Does the Asbestosis interfere with wearing a respirator mask?
No
Does the Asbestosis interfere with wearing a respirator mask?
Yes
9 - Asthma
*
9 - Asthma
No
9 - Asthma
Yes
Are you currently diagnosed with Asthma?
*
Are you currently diagnosed with Asthma?
No
Are you currently diagnosed with Asthma?
Yes
Are you currently on medication for Asthma?
*
Are you currently on medication for Asthma?
No
Are you currently on medication for Asthma?
Yes
Do you have recurring complications from Asthma?
*
Do you have recurring complications from Asthma?
No
Do you have recurring complications from Asthma?
Yes
Does the Asthma interfere with wearing a respirator mask?
*
Does the Asthma interfere with wearing a respirator mask?
No
Does the Asthma interfere with wearing a respirator mask?
Yes
10 - Chronic Bronchitis
*
10 - Chronic Bronchitis
No
10 - Chronic Bronchitis
Yes
Are you currently diagnosed with Chronic Bronchitis?
*
Are you currently diagnosed with Chronic Bronchitis?
No
Are you currently diagnosed with Chronic Bronchitis?
Yes
Are you currently on medication for Chronic Bronchitis?
*
Are you currently on medication for Chronic Bronchitis?
No
Are you currently on medication for Chronic Bronchitis?
Yes
Do you have recurring complications from Chronic Bronchitis?
*
Do you have recurring complications from Chronic Bronchitis?
No
Do you have recurring complications from Chronic Bronchitis?
Yes
Does the Chronic Bronchitis interfere with wearing a respirator mask?
*
Does the Chronic Bronchitis interfere with wearing a respirator mask?
No
Does the Chronic Bronchitis interfere with wearing a respirator mask?
Yes
11 - Emphysema
*
11 - Emphysema
No
11 - Emphysema
Yes
Are you currently diagnosed with Emphysema?
*
Are you currently diagnosed with Emphysema?
No
Are you currently diagnosed with Emphysema?
Yes
Are you currently on medication for Emphysema?
*
Are you currently on medication for Emphysema?
No
Are you currently on medication for Emphysema?
Yes
Do you have recurring complications from Emphysema?
*
Do you have recurring complications from Emphysema?
No
Do you have recurring complications from Emphysema?
Yes
Does the Emphysema interfere with wearing a respirator mask?
*
Does the Emphysema interfere with wearing a respirator mask?
No
Does the Emphysema interfere with wearing a respirator mask?
Yes
12 - Pneumonia
*
12 - Pneumonia
No
12 - Pneumonia
Yes
Are you currently diagnosed with Pneumonia?
*
Are you currently diagnosed with Pneumonia?
No
Are you currently diagnosed with Pneumonia?
Yes
Are you currently on medication for Pneumonia?
*
Are you currently on medication for Pneumonia?
No
Are you currently on medication for Pneumonia?
Yes
Do you have recurring complications from Pneumonia?
*
Do you have recurring complications from Pneumonia?
No
Do you have recurring complications from Pneumonia?
Yes
Does the Pneumonia interfere with wearing a respirator mask?
*
Does the Pneumonia interfere with wearing a respirator mask?
No
Does the Pneumonia interfere with wearing a respirator mask?
Yes
13 - Tuberculosis
*
13 - Tuberculosis
No
13 - Tuberculosis
Yes
Are you currently diagnosed with Tuberculosis?
*
Are you currently diagnosed with Tuberculosis?
No
Are you currently diagnosed with Tuberculosis?
Yes
Are you currently on medication for Tuberculosis?
*
Are you currently on medication for Tuberculosis?
No
Are you currently on medication for Tuberculosis?
Yes
Do you have recurring complications from Tuberculosis?
*
Do you have recurring complications from Tuberculosis?
No
Do you have recurring complications from Tuberculosis?
Yes
Does the Tuberculosis interfere with wearing a respirator mask?
*
Does the Tuberculosis interfere with wearing a respirator mask?
No
Does the Tuberculosis interfere with wearing a respirator mask?
Yes
14 - Silicosis
*
14 - Silicosis
No
14 - Silicosis
Yes
Are you currently diagnosed with Silicosis?
*
Are you currently diagnosed with Silicosis?
No
Are you currently diagnosed with Silicosis?
Yes
Are you currently on medication for Silicosis?
*
Are you currently on medication for Silicosis?
No
Are you currently on medication for Silicosis?
Yes
Do you have recurring complications from Silicosis?
*
Do you have recurring complications from Silicosis?
No
Do you have recurring complications from Silicosis?
Yes
Does the Silicosis interfere with wearing a respirator mask?
*
Does the Silicosis interfere with wearing a respirator mask?
No
Does the Silicosis interfere with wearing a respirator mask?
Yes
15 - Pneumothorax (collapsed lung)
*
15 - Pneumothorax (collapsed lung)
No
15 - Pneumothorax (collapsed lung)
Yes
Are you currently diagnosed with a collapsed lung?
*
Are you currently diagnosed with a collapsed lung?
No
Are you currently diagnosed with a collapsed lung?
Yes
Are you currently on medication for a collapsed lung?
*
Are you currently on medication for a collapsed lung?
No
Are you currently on medication for a collapsed lung?
Yes
Do you have recurring complications from a collapsed lung?
*
Do you have recurring complications from a collapsed lung?
No
Do you have recurring complications from a collapsed lung?
Yes
Does the collapsed lung interfere with wearing a respirator mask?
*
Does the collapsed lung interfere with wearing a respirator mask?
No
Does the collapsed lung interfere with wearing a respirator mask?
Yes
16 - Lung cancer
*
16 - Lung cancer
No
16 - Lung cancer
Yes
17 - Broken ribs
*
17 - Broken ribs
No
17 - Broken ribs
Yes
Are you currently diagnosed with a broken rib?
*
Are you currently diagnosed with a broken rib?
No
Are you currently diagnosed with a broken rib?
Yes
Are you currently on medication for a broken rib?
*
Are you currently on medication for a broken rib?
No
Are you currently on medication for a broken rib?
Yes
Do you have recurring complications from a broken rib?
*
Do you have recurring complications from a broken rib?
No
Do you have recurring complications from a broken rib?
Yes
Does the broken rib interfere with wearing a respirator mask?
*
Does the broken rib interfere with wearing a respirator mask?
No
Does the broken rib interfere with wearing a respirator mask?
Yes
18 - Any chest injuries or surgeries
*
18 - Any chest injuries or surgeries
No
18 - Any chest injuries or surgeries
Yes
Describe the nature of your chest injury or surgery.
*
When did the chest injury or surgery occur?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Do you have any recurring complications from the chest injury or surgery?
*
Do you have any recurring complications from the chest injury or surgery?
No
Do you have any recurring complications from the chest injury or surgery?
Yes
Does the chest injury or surgery interfere with wearing a respirator mask?
*
Does the chest injury or surgery interfere with wearing a respirator mask?
No
Does the chest injury or surgery interfere with wearing a respirator mask?
Yes
19 - Any other lung problem
*
19 - Any other lung problem
No
19 - Any other lung problem
Yes
Describe the nature of your lung problem.
*
When did the lung problem occur?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Do you have any recurring complications from the lung problem?
*
Do you have any recurring complications from the lung problem?
No
Do you have any recurring complications from the lung problem?
Yes
Does the lung problem interfere with wearing a respirator mask?
*
Does the lung problem interfere with wearing a respirator mask?
No
Does the lung problem interfere with wearing a respirator mask?
Yes
Do you currently have any of the following symptoms of pulmonary or lung illness?
20 - Shortness of breath
*
20 - Shortness of breath
No
20 - Shortness of breath
Yes
How often do you experience this shortness of breath?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this shortness of breath?
*
Do you have recurring complications from this shortness of breath?
No
Do you have recurring complications from this shortness of breath?
Yes
Does this shortness of breath interfere with wearing a respirator mask?
*
Does this shortness of breath interfere with wearing a respirator mask?
No
Does this shortness of breath interfere with wearing a respirator mask?
Yes
21 - Shortness of breath when walking fast on level ground or walking up a slight hill or incline
*
21 - Shortness of breath when walking fast on level ground or walking up a slight hill or incline
No
21 - Shortness of breath when walking fast on level ground or walking up a slight hill or incline
Yes
How often do you experience this shortness of breath?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this shortness of breath?
*
Do you have recurring complications from this shortness of breath?
No
Do you have recurring complications from this shortness of breath?
Yes
Does this shortness of breath interfere with wearing a respirator mask?
*
Does this shortness of breath interfere with wearing a respirator mask?
No
Does this shortness of breath interfere with wearing a respirator mask?
Yes
22 - Shortness of breath when walking with other people at an ordinary pace on level ground
*
22 - Shortness of breath when walking with other people at an ordinary pace on level ground
No
22 - Shortness of breath when walking with other people at an ordinary pace on level ground
Yes
How often do you experience this shortness of breath?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this shortness of breath?
*
Do you have recurring complications from this shortness of breath?
No
Do you have recurring complications from this shortness of breath?
Yes
Does this shortness of breath interfere with wearing a respirator mask?
*
Does this shortness of breath interfere with wearing a respirator mask?
No
Does this shortness of breath interfere with wearing a respirator mask?
Yes
23 - Have to stop for breath when walking at your own pace on level ground
*
23 - Have to stop for breath when walking at your own pace on level ground
No
23 - Have to stop for breath when walking at your own pace on level ground
Yes
How often do you experience this shortness of breath?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this shortness of breath?
*
Do you have recurring complications from this shortness of breath?
No
Do you have recurring complications from this shortness of breath?
Yes
Does this shortness of breath interfere with wearing a respirator mask?
*
Does this shortness of breath interfere with wearing a respirator mask?
No
Does this shortness of breath interfere with wearing a respirator mask?
Yes
24 - Shortness of breath when washing or dressing yourself
*
24 - Shortness of breath when washing or dressing yourself
No
24 - Shortness of breath when washing or dressing yourself
Yes
How often do you experience this shortness of breath?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this shortness of breath?
*
Do you have recurring complications from this shortness of breath?
No
Do you have recurring complications from this shortness of breath?
Yes
Does this shortness of breath interfere with wearing a respirator mask?
*
Does this shortness of breath interfere with wearing a respirator mask?
No
Does this shortness of breath interfere with wearing a respirator mask?
Yes
25 - Shortness of breath that interferes with your job
*
25 - Shortness of breath that interferes with your job
No
25 - Shortness of breath that interferes with your job
Yes
How often do you experience this shortness of breath?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this shortness of breath?
*
Do you have recurring complications from this shortness of breath?
No
Do you have recurring complications from this shortness of breath?
Yes
Does this shortness of breath interfere with wearing a respirator mask?
*
Does this shortness of breath interfere with wearing a respirator mask?
No
Does this shortness of breath interfere with wearing a respirator mask?
Yes
26 - Coughing that produces phlegm (thick sputum)
*
26 - Coughing that produces phlegm (thick sputum)
No
26 - Coughing that produces phlegm (thick sputum)
Yes
How often do you experience this coughing?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this coughing?
*
Do you have recurring complications from this coughing?
No
Do you have recurring complications from this coughing?
Yes
Does this coughing interfere with wearing a respirator mask?
*
Does this coughing interfere with wearing a respirator mask?
No
Does this coughing interfere with wearing a respirator mask?
Yes
27 - Coughing that wakes you early in the morning
*
27 - Coughing that wakes you early in the morning
No
27 - Coughing that wakes you early in the morning
Yes
How often do you experience this coughing?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this coughing?
*
Do you have recurring complications from this coughing?
No
Do you have recurring complications from this coughing?
Yes
Does this coughing interfere with wearing a respirator mask?
*
Does this coughing interfere with wearing a respirator mask?
No
Does this coughing interfere with wearing a respirator mask?
Yes
28 - Coughing that occurs mostly when you are lying down
*
28 - Coughing that occurs mostly when you are lying down
No
28 - Coughing that occurs mostly when you are lying down
Yes
How often do you experience this coughing?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this coughing?
*
Do you have recurring complications from this coughing?
No
Do you have recurring complications from this coughing?
Yes
Does this coughing interfere with wearing a respirator mask?
*
Does this coughing interfere with wearing a respirator mask?
No
Does this coughing interfere with wearing a respirator mask?
Yes
29 - Coughing up blood in the last month
*
29 - Coughing up blood in the last month
No
29 - Coughing up blood in the last month
Yes
30 - Wheezing
*
30 - Wheezing
No
30 - Wheezing
Yes
How often do you experience wheezing?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from wheezing?
*
Do you have recurring complications from wheezing?
No
Do you have recurring complications from wheezing?
Yes
Does wheezing interfere with wearing a respirator mask?
*
Does wheezing interfere with wearing a respirator mask?
No
Does wheezing interfere with wearing a respirator mask?
Yes
31 - Wheezing that interferes with your job
*
31 - Wheezing that interferes with your job
No
31 - Wheezing that interferes with your job
Yes
Describe the nature of the wheezing that interferes with your job.
*
How often does wheezing interfere with your job?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
32 - Chest pain when you breathe deeply
*
32 - Chest pain when you breathe deeply
No
32 - Chest pain when you breathe deeply
Yes
How often do you experience chest pain when you breathe deeply?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from chest pain when you breathe deeply?
*
Do you have recurring complications from chest pain when you breathe deeply?
No
Do you have recurring complications from chest pain when you breathe deeply?
Yes
Does chest pain when you breathe deeply interfere with wearing a respirator mask?
*
Does chest pain when you breathe deeply interfere with wearing a respirator mask?
No
Does chest pain when you breathe deeply interfere with wearing a respirator mask?
Yes
33 - Any other symptoms that you think may be related to lung problems
*
33 - Any other symptoms that you think may be related to lung problems
No
33 - Any other symptoms that you think may be related to lung problems
Yes
Describe the nature of the symptoms that you think may be related to lung problems.
*
How often do these symptoms occur?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for these symptoms?
*
Are you currently seeing a doctor for these symptoms?
No
Are you currently seeing a doctor for these symptoms?
Yes
Do these symptoms interfere with wearing a respirator mask?
*
Do these symptoms interfere with wearing a respirator mask?
No
Do these symptoms interfere with wearing a respirator mask?
Yes
Have you ever had any of the following cardiovascular or heart problems?
34 - Heart attack
*
34 - Heart attack
No
34 - Heart attack
Yes
When did you have the heart attack?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Are you currently seeing a cardiologist?
*
Are you currently seeing a cardiologist?
No
Are you currently seeing a cardiologist?
Yes
Are you currently on medication related to the heart attack?
*
Are you currently on medication related to the heart attack?
No
Are you currently on medication related to the heart attack?
Yes
Do you have chest pain when wearing the respirator mask?
*
Do you have chest pain when wearing the respirator mask?
No
Do you have chest pain when wearing the respirator mask?
Yes
Does the heart attack interfere with wearing the respirator mask?
*
Does the heart attack interfere with wearing the respirator mask?
No
Does the heart attack interfere with wearing the respirator mask?
Yes
35 - Stroke
*
35 - Stroke
No
35 - Stroke
Yes
When did you have the stroke?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Are you currently seeing a neurologist?
*
Are you currently seeing a neurologist?
No
Are you currently seeing a neurologist?
Yes
Are you currently on medication related to the stroke?
*
Are you currently on medication related to the stroke?
No
Are you currently on medication related to the stroke?
Yes
Does the stroke interfere with wearing the respirator mask?
*
Does the stroke interfere with wearing the respirator mask?
No
Does the stroke interfere with wearing the respirator mask?
Yes
36 - Angina
*
36 - Angina
No
36 - Angina
Yes
When did you have the angina?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Are you currently seeing a cardiologist?
*
Are you currently seeing a cardiologist?
No
Are you currently seeing a cardiologist?
Yes
Are you currently on medication related to the angina?
*
Are you currently on medication related to the angina?
No
Are you currently on medication related to the angina?
Yes
Do you have chest pain when wearing the respirator mask?
*
Do you have chest pain when wearing the respirator mask?
No
Do you have chest pain when wearing the respirator mask?
Yes
Does the angina interfere with wearing the respirator mask?
*
Does the angina interfere with wearing the respirator mask?
No
Does the angina interfere with wearing the respirator mask?
Yes
37 - Heart failure
*
37 - Heart failure
No
37 - Heart failure
Yes
When did you have the heart failure?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Are you currently seeing a cardiologist?
*
Are you currently seeing a cardiologist?
No
Are you currently seeing a cardiologist?
Yes
Are you currently on medication related to the heart failure?
*
Are you currently on medication related to the heart failure?
No
Are you currently on medication related to the heart failure?
Yes
Do you have chest pain when wearing the respirator mask?
*
Do you have chest pain when wearing the respirator mask?
No
Do you have chest pain when wearing the respirator mask?
Yes
Does the heart failure interfere with wearing the respirator mask?
*
Does the heart failure interfere with wearing the respirator mask?
No
Does the heart failure interfere with wearing the respirator mask?
Yes
38 - Swelling in your legs or feet (not caused by walking)
*
38 - Swelling in your legs or feet (not caused by walking)
No
38 - Swelling in your legs or feet (not caused by walking)
Yes
Do you currently have swelling in your legs or feet?
*
Do you currently have swelling in your legs or feet?
No
Do you currently have swelling in your legs or feet?
Yes
How often do your legs or feet swelling while you are at work?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Are you currently on medication related to this swelling?
*
Are you currently on medication related to this swelling?
No
Are you currently on medication related to this swelling?
Yes
Does the swelling interfere with wearing the respirator mask?
*
Does the swelling interfere with wearing the respirator mask?
No
Does the swelling interfere with wearing the respirator mask?
Yes
39 - Heart arrhythmia (heart beating irregularly)
*
39 - Heart arrhythmia (heart beating irregularly)
No
39 - Heart arrhythmia (heart beating irregularly)
Yes
When did you have Heart Arrhythmia?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
What type of Heart Arrhythmia did you have?
*
Tachycardia
Bradycardia
Supraventricular
Ventricular
Unknown
Select
Are you currently on medication for Heart Arrhythmia?
*
Are you currently on medication for Heart Arrhythmia?
No
Are you currently on medication for Heart Arrhythmia?
Yes
Do you have recurring complications from Heart Arrhythmia?
*
Do you have recurring complications from Heart Arrhythmia?
No
Do you have recurring complications from Heart Arrhythmia?
Yes
Does the Heart Arrhythmia interfere with wearing a respirator mask?
*
Does the Heart Arrhythmia interfere with wearing a respirator mask?
No
Does the Heart Arrhythmia interfere with wearing a respirator mask?
Yes
40 - High blood pressure
*
40 - High blood pressure
No
40 - High blood pressure
Yes
Are you currently diagnosed with high blood pressure?
*
Are you currently diagnosed with high blood pressure?
No
Are you currently diagnosed with high blood pressure?
Yes
Are you currently on medication for high blood pressure?
*
Are you currently on medication for high blood pressure?
No
Are you currently on medication for high blood pressure?
Yes
Do you have recurring complications from high blood pressure?
*
Do you have recurring complications from high blood pressure?
No
Do you have recurring complications from high blood pressure?
Yes
Does the high blood pressure interfere with wearing a respirator?
*
Does the high blood pressure interfere with wearing a respirator?
No
Does the high blood pressure interfere with wearing a respirator?
Yes
41 - Any other heart problem that you've been told about
*
41 - Any other heart problem that you've been told about
No
41 - Any other heart problem that you've been told about
Yes
Describe the nature of your heart problem.
*
When did the heart problem occur?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Do you have any recurring complications from the heart problem?
*
Do you have any recurring complications from the heart problem?
No
Do you have any recurring complications from the heart problem?
Yes
Does the heart problem interfere with wearing a respirator mask?
*
Does the heart problem interfere with wearing a respirator mask?
No
Does the heart problem interfere with wearing a respirator mask?
Yes
Have you ever had any of the following cardiovascular or heart symptoms?
42 - Frequent pain or tightness in your chest
*
42 - Frequent pain or tightness in your chest
No
42 - Frequent pain or tightness in your chest
Yes
How often do you experience pain or tightness in your chest?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a cardiologist?
*
Are you currently seeing a cardiologist?
No
Are you currently seeing a cardiologist?
Yes
Are you currently on medication related to the pain or tightness in your chest?
*
Are you currently on medication related to the pain or tightness in your chest?
No
Are you currently on medication related to the pain or tightness in your chest?
Yes
Do you have chest pain or tightness when wearing the respirator mask?
*
Do you have chest pain or tightness when wearing the respirator mask?
No
Do you have chest pain or tightness when wearing the respirator mask?
Yes
43 - Pain or tightness in your chest during physical activity
*
43 - Pain or tightness in your chest during physical activity
No
43 - Pain or tightness in your chest during physical activity
Yes
How often do you experience pain or tightness in your chest during physical activity?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a cardiologist?
*
Are you currently seeing a cardiologist?
No
Are you currently seeing a cardiologist?
Yes
Are you currently on medication related to the pain or tightness in your chest during physical activity?
*
Are you currently on medication related to the pain or tightness in your chest during physical activity?
No
Are you currently on medication related to the pain or tightness in your chest during physical activity?
Yes
Do you have chest pain or tightness when wearing the respirator mask?
*
Do you have chest pain or tightness when wearing the respirator mask?
No
Do you have chest pain or tightness when wearing the respirator mask?
Yes
44 - Pain or tightness in your chest that interferes with your job
*
44 - Pain or tightness in your chest that interferes with your job
No
44 - Pain or tightness in your chest that interferes with your job
Yes
How often does the pain or tightness in your chest interfere with your job?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a cardiologist?
*
Are you currently seeing a cardiologist?
No
Are you currently seeing a cardiologist?
Yes
45 - In the past two years, have you noticed your heart skipping or missing a beat
*
45 - In the past two years, have you noticed your heart skipping or missing a beat
No
45 - In the past two years, have you noticed your heart skipping or missing a beat
Yes
Describe the nature of your heart skipping or missing a beat.
*
How often do these symptoms occur?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for these symptoms?
*
Are you currently seeing a doctor for these symptoms?
No
Are you currently seeing a doctor for these symptoms?
Yes
Do these symptoms interfere with wearing a respirator mask?
*
Do these symptoms interfere with wearing a respirator mask?
No
Do these symptoms interfere with wearing a respirator mask?
Yes
46 - Heartburn or indigestion that is not related to eating
*
46 - Heartburn or indigestion that is not related to eating
No
46 - Heartburn or indigestion that is not related to eating
Yes
How often do you experience heartburn that is not related to eating?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for this condition?
*
Are you currently seeing a doctor for this condition?
No
Are you currently seeing a doctor for this condition?
Yes
Do you have recurring complications from this heartburn or indigestion?
*
Do you have recurring complications from this heartburn or indigestion?
No
Do you have recurring complications from this heartburn or indigestion?
Yes
Do you have hearburn or indigestion when wearing the respirator mask?
*
Do you have hearburn or indigestion when wearing the respirator mask?
No
Do you have hearburn or indigestion when wearing the respirator mask?
Yes
Does this heartburn or indigestion interfere with wearing a respirator mask?
*
Does this heartburn or indigestion interfere with wearing a respirator mask?
No
Does this heartburn or indigestion interfere with wearing a respirator mask?
Yes
47 - Any other symptoms that you think may be related to heart or circulation problems
*
47 - Any other symptoms that you think may be related to heart or circulation problems
No
47 - Any other symptoms that you think may be related to heart or circulation problems
Yes
Describe the nature of the symptoms that you think may be related to heart or circulation problems.
*
How often do these symptoms occur?
*
Rarely
Occasionally
Frequently
Every Day
Select
Are you currently seeing a doctor for these symptoms?
*
Are you currently seeing a doctor for these symptoms?
No
Are you currently seeing a doctor for these symptoms?
Yes
Do these symptoms interfere with wearing a respirator mask?
*
Do these symptoms interfere with wearing a respirator mask?
No
Do these symptoms interfere with wearing a respirator mask?
Yes
Do you currently take medication for any of the following problems?
48 - Breathing or lung problems
*
48 - Breathing or lung problems
No
48 - Breathing or lung problems
Yes
What is the name of the medication?
*
Does the medication have any side effects that interfere with wearing the respirator mask?
*
Does the medication have any side effects that interfere with wearing the respirator mask?
No
Does the medication have any side effects that interfere with wearing the respirator mask?
Yes
49 - Heart trouble
*
49 - Heart trouble
No
49 - Heart trouble
Yes
What is the name of the medication?
*
Does the medication have any side effects that interfere with wearing the respirator mask?
*
Does the medication have any side effects that interfere with wearing the respirator mask?
No
Does the medication have any side effects that interfere with wearing the respirator mask?
Yes
50 - Blood pressure
*
50 - Blood pressure
No
50 - Blood pressure
Yes
What is the name of the medication?
*
Does the medication have any side effects that interfere with wearing the respirator mask?
*
Does the medication have any side effects that interfere with wearing the respirator mask?
No
Does the medication have any side effects that interfere with wearing the respirator mask?
Yes
51 - Seizures (fits)
*
51 - Seizures (fits)
No
51 - Seizures (fits)
Yes
What is the name of the medication?
*
Does the medication have any side effects that interfere with wearing the respirator mask?
*
Does the medication have any side effects that interfere with wearing the respirator mask?
No
Does the medication have any side effects that interfere with wearing the respirator mask?
Yes
If you've used a respirator, have you ever had any of the following problems?
52 - Eye irritation
*
52 - Eye irritation
No
52 - Eye irritation
Yes
Are you currently on medication for eye irritation?
*
Are you currently on medication for eye irritation?
No
Are you currently on medication for eye irritation?
Yes
Do you have recurring complications from eye irritation?
*
Do you have recurring complications from eye irritation?
No
Do you have recurring complications from eye irritation?
Yes
Does the eye irritation interfere with wearing a respirator?
*
Does the eye irritation interfere with wearing a respirator?
No
Does the eye irritation interfere with wearing a respirator?
Yes
53 - Skin allergies or rashes
*
53 - Skin allergies or rashes
No
53 - Skin allergies or rashes
Yes
Are you currently on medication for skin irritation?
*
Are you currently on medication for skin irritation?
No
Are you currently on medication for skin irritation?
Yes
Do you have recurring complications from skin irritation?
*
Do you have recurring complications from skin irritation?
No
Do you have recurring complications from skin irritation?
Yes
Does the skin irritation interfere with wearing a respirator?
*
Does the skin irritation interfere with wearing a respirator?
No
Does the skin irritation interfere with wearing a respirator?
Yes
54 - Anxiety
*
54 - Anxiety
No
54 - Anxiety
Yes
Are you currently on medication for anxiety?
*
Are you currently on medication for anxiety?
No
Are you currently on medication for anxiety?
Yes
Do you have recurring complications from anxiety?
*
Do you have recurring complications from anxiety?
No
Do you have recurring complications from anxiety?
Yes
Does the anxiety interfere with wearing a respirator?
*
Does the anxiety interfere with wearing a respirator?
No
Does the anxiety interfere with wearing a respirator?
Yes
55 - General weakness or fatigue
*
55 - General weakness or fatigue
No
55 - General weakness or fatigue
Yes
Are you currently on medication for fatigue?
*
Are you currently on medication for fatigue?
No
Are you currently on medication for fatigue?
Yes
Do you have recurring complications from fatigue?
*
Do you have recurring complications from fatigue?
No
Do you have recurring complications from fatigue?
Yes
Does the fatigue interfere with wearing a respirator?
*
Does the fatigue interfere with wearing a respirator?
No
Does the fatigue interfere with wearing a respirator?
Yes
56 - Any other problem that interferes with your use of a respirator?
*
56 - Any other problem that interferes with your use of a respirator?
No
56 - Any other problem that interferes with your use of a respirator?
Yes
Describe the nature of your problem.
*
When did the problem occur?
*
This Year
1+ Years Ago
5+ Years Ago
10+ Years Ago
Select
Do you have any recurring complications from the problem?
*
Do you have any recurring complications from the problem?
No
Do you have any recurring complications from the problem?
Yes
Does the problem interfere with wearing a respirator mask?
*
Does the problem interfere with wearing a respirator mask?
No
Does the problem interfere with wearing a respirator mask?
Yes
