Frontier Wellness of Ross, OH

WELCOME TO

Frontier Wellness

At Frontier Wellness, we are dedicated to enhancing the health and well-being of Ross and its surrounding communities. Through comprehensive medical services tailored to all ages, we prioritize health promotion, disease prevention, and compassionate care. By collaborating closely with our community and honoring our agricultural roots, we strive to exceed expectations and foster a healthier future for all.

WELCOME TO

Frontier Wellness

At Frontier Wellness, we are dedicated to enhancing the health and well-being of Ross and its surrounding communities. Through comprehensive medical services tailored to all ages, we prioritize health promotion, disease prevention, and compassionate care. By collaborating closely with our community and honoring our agricultural roots, we strive to exceed expectations and foster a healthier future for all.

OSHA Respiratory Medical Questionnaire

First Name *

Last Name *

Email *

Social Security # *

Address

Street Address

City

State

Country

Postal code

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee: Can you read (check one) xYes xNo

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator

Todays Date

Full Name *

Your Age *

Sex *

Male

Female

Your Height *

Your Weight *

Your Job TItle *

Phone *

Best time to call *

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

Yes

No

Check the type or respirator you will use *

Have you worn a respirator? *

Yes

No

If Yes to use of respirator, what type?

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.

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?

Yes

No

2. Have you ever had any of the following conditions?

Seizures ( fits )

Yes

No

Diabetes ( sugar disease )

Yes

No

Allergic reactions that interfere with your breathing

Yes

No

Calustrophobia ( fear of closed-in places )

Yes

No

Trouble smelling odors

Yes

No

3. Have you ever had any of the following pulmonary or lung problems?

Asbestosis

Yes

No

Asthma

Yes

No

Chronic bronchitis

Yes

No

Emphysema

Yes

No

Pneumonia

Yes

No

Tuberculosis

Yes

No

Silicosis

Yes

No

Pneumothorax ( collapsed lung )

Yes

No

Lung cancer

Yes

No

Broken ribs

Yes

No

Any chest injuries or surgeries

Yes

No

Any other lung problem that you've been told about

Yes

No

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

Shortness of breath

Yes

No

Shortness of breath when walking fast on level ground or walking up a slight hill or incline

Yes

No

Shortness of breath when walking with other people at an ordinary pace on level ground

Yes

No

Have to stop for breath when walking at your own pace on level ground

Yes

No

Shortness of breath when washing or dressing yourself

Yes

No

Shortness of breath that interferes with your job

Yes

No

Coughing that produces phlegm (thick sputum)

Yes

No

Coughing that wakes you up early in the morning

Yes

No

Coughing that occurs mostly when you are lying down

Yes

No

Coughing up blood in the last month

Yes

No

Wheezing

Yes

No

Wheezing that interferes with your job

Yes

No

Chest pain when you breathe deeply

Yes

No

Any other symptoms that you think may be related to lung problems

Yes

No

5. Have you ever had any of the following heart problems?

Heart attack

Yes

No

Stroke

Yes

No

Angina

Yes

No

Heart failure

Yes

No

Swelling in your legs or feet ( not caused by walking )

Yes

No

Heart arrhythmia (heart beating irregularly)

Yes

No

High blood pressure

Yes

No

Any other heart problem that you've been told about

Yes

No

6. Have you ever had any of the following cardiovascular or heart symptoms?

Frequent pain or tightness in your chest

Yes

No

Pain or tightness in your chest during physical activity

Yes

No

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

Heartburn or indigestion that is not re ate to eating

Yes

No

Any other symptoms that you think may be related to heart or circulation problems

Yes

No

7. Do you currently take medication for any of the following problems?

* Breathing or lung problem

Yes

No

* Heart Trouble

Yes

No

* Blood Pressure

Yes

No

* Seizures

Yes

No

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 x and go to question 9:)

Eye irritation

Yes

No

Skin allergies or rashes

Yes

No

Anxiety

Yes

No

General weakness or fatigue

Yes

No

Any other problem that interferes with your use of a respirator

Yes

No

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

Allow one of our representer to review your answer

Yes

No

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

Yes

No

11. Do you currently have any of the following vision problems?

Wear contact lenses

Yes

No

Wear glasses

Yes

No

Color blind

Yes

No

Any other eye or vision problem

Yes

No

12. Have you ever had an injury to your ears?

Broken ear drum

Yes

No

13. Do you currently have any of the following hearing problems?

Difficulty hearing

Yes

No

Wear a hearing aid

Yes

No

Any other hearing or ear problem

Yes

No

14. Have you ever had a back injury

Back injury

Yes

No

15. Do you currently have any of the following musculoskeletal problems?

Weakness in any of your arms, hands, legs, or feet

Yes

No

Back Pain

Yes

No

Difficulty fully moving your arms and legs

Yes

No

Pain or stiffness when you lean forward or backward at the waist

Yes

No

Difficulty fully moving your head up or down

Yes

No

Difficulty fully moving your head side to side

Yes

No

Difficulty bending at your knees

Yes

No

Difficulty squatting to the ground

Yes

No

Climbing a flight of stairs or a ladder carrying more than 25 lbs

Yes

No

Any other muscle or skeletal problem that interferes with using a respirator

Yes

No

Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion

of the health care professional who will review the questionnaire.

1. 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

If "yes," 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

2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gasses, fumes, or dust), or have you come into skin contact with hazardous chemicals

Yes

No

If" Yes," name the chemicals if you know them

3. Have you ever worked with any of the materials, or under any of the conditions, listed below

Asbestos

Yes

No

Silica (e.g., in sandblasting)

Yes

No

Tungsten/cobalt (e.g., grinding or welding this material)

Yes

No

Berylium

Yes

No

Aluminum

Yes

No

Coal ( for example, mining )

Yes

No

Iron

Yes

No

Tin

Yes

No

Dusty environments

Yes

No

Any other hazardous exposures

Yes

No

If "Yes," describe these exposures

4. List any second jobs or side businesses you have

5. List your previous occupations

6. List your current and previous hobbies

7. Have you been in the military services?

Yes

No

If "yes," were you exposed to biological or chemical agents (either in training or combat)

Yes

No

8. Have you ever worked on a HAZMAT team?

Yes

No

9. 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

If "yes," name the medications if you know them

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

HEPA Filters

Yes

No

Canisters (for example, gas masks)

Yes

No

Cartridges

Yes

No

11. How often are you expected to use the respirator(s):

Escape only (no rescue)

Yes

No

Emergency rescue only

Yes

No

Less than 5 hours per week

Yes

No

Less than 2 hours per day

Yes

No

2 to 4 hours per day

Yes

No

Over 4 hours per day

Yes

No

12. During the period you are using the respirator(s), is your work effort

Light ( less than 200 kcal per hour )

Yes

No

If "yes" how long does this period last during the average shift

Examples ofa light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (l -3 lbs.) or controlling machines.

Moderate 200 to 350 kcal per hour

Yes

No

"yes," how long does this period last during the average shift

Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.

Heavy above 350 kcal per hour

Yes

No

If "Yes," how long this period last during the average shift?

Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).

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

Yes

No

If "Yes," describe this protective clothing and/or equipment

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

Yes

No

15. Will you be working under humid conditions

Yes

No

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

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

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

Name of the first toxic substance

Estimated maximum exposure level per shift

Duration of exposure per shift

Name of the second toxic substance

Estimated Maximum Exposure level per shift 2

Duration of exposure per shift 2

Name of the third toxic substance

Estimated maximum exposure level per shift 3

Duration of exposure per shift 3

The name of any other toxic substances that you'll be exposed to while using your respirator

19. 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)

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.