| Document Date: 2014-03-05 18:54:07
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MedicalCondition Eye irritation Yes No Skin allergies / Yes Claustrophobia / Shortness of breath / Yes No Allergic reactions / pain / Yes No Any chest injuries / back injury / injury / lung illness / lung problems Heart trouble Yes Blood pressure Yes Seizures / indigestion / sugar disease / Chest pain / Asbestosis Yes No Asthma Yes No Chronic bronchitis Yes No Emphysema Yes No Pneumonia Yes No Tuberculosis Yes No Silicosis Yes No Pneumothorax / Coughing / Seizures (fits) Yes No Diabetes / Wheezing / Yes Heart arrhythmia / / MedicalTreatment surgeries / / Organization Occupational Safety and Health Administration / / Position supervisor / Yes No Anxiety Yes No General / /
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Environmental Health & Safety OSHA Respirator Medical Evaluation Questionnaire Form SF[removed]To The Employer: Answers to the questions in Section 1, and to question 9 in Section 2, do not require a medical examination.