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pdfDEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
OMB Control Number: 1660-0100
Expires: XX/XX/XXXX
Center for Domestic Preparedness
RESPIRATORY MEDICAL EVALUATION QUESTIONNAIRE FOR STUDENTS
Purpose: To identify individuals having medical conditions (or past respirator experiences) who may require definitive medical evaluation
by a Physician or other Licensed Health Care Professionals (PLHCP) prior to the issuance of protective masks. Only the PLHCP will
review and/or have access to the information provided in this medical questionnaire.
Patient Identification Information:
Date:
Class Number:
Name:
FEMA SID:
Gender:
Reviewed by:
Job Title:
Age:
Height:
Phone:
Weight:
DRAFT
FOR OFFICIAL USE ONLY
The Privacy Act of 1974, 5 U.S.C. 552A, prohibits unauthorized release of personal data contained herein. Routine use of the
information may be used to carry out follow-up evaluations. The unauthorized Disclosure of information contained in this form could
result in a violation of an individual’s right to privacy. Minimum security measures require that the information contained herein be
used only by authorized persons in the conduct of official business. Unauthorized disclosure of personal information, to any person
not entitled to receive it, many result in a fine not more than $5,000.00.
Please mark “YES” or “NO” to the following questions.
1.
Have you worn a respirator/mask, Self-Contained Breathing Apparatus (SCBA), Air-Purifying Respirator
(APR), or Powered Air-Purifying Respirator (PAPR)?
Yes
No
If yes, what kind:
2.
Do you currently smoke tobacco, or have you smoked tobacco in the last month?
Yes
No
3.
Have you ever had seizures (as an adult or/and currently under treatment)?
Yes
No
If yes, have you been seizure-free for past 6 months?
Yes
No
4.
Have you ever had diabetes (sugar disease)?
Yes
No
5.
Have you ever had allergic reactions that interfere with your breathing?
Yes
No
If yes, date occurred:
Allergic reaction to:
6.
Have you ever had claustrophobia (fear of closed-in places)?
Yes
No
7.
Have you had a heat injury in the past 12 months that required IV fluids or hospitalization?
Yes
No
If yes, do you have any special considerations while training in heat?
8.
Have you ever had asbestosis?
Yes
No
9.
Have you ever had asthma as an adult?
Yes
No
10.
Have you ever had chronic bronchitis?
Yes
No
If yes, date:
FEMA Form FF-008-FY-22-125 (2/22)
Page 1 of 5
Please mark “YES” or “NO” to the following questions.
11.
Have you ever had emphysema?
Yes
No
12.
Have you ever had pneumonia?
Yes
No
Yes
No
If yes, date:
13.
Have you ever had a tuberculosis diagnosis (positive TB skin test)?
If yes, date of last negative (normal) chest x-ray:
14.
Have you ever had silicosis (inhalation of silica/quartz dust)?
Yes
No
15.
Have you ever had pneumothorax (collapsed lung)?
Yes
No
16.
Have you ever had lung cancer, breast, colon, skin radiation, or chemotherapy?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, date:
17.
Have you ever had broken ribs?
18.
Have you ever had any chest injuries?
19.
Have you ever had any chest surgery(s)?
If yes, what procedure:
20.
If yes, date:
If yes, date:
DRAFT
Date:
Any other lung problem that you’ve been told about?
If yes, describe:
21.
Do you currently suffer from shortness of breath (not related to weight or sedentary lifestyle)?
Yes
No
22.
Do you currently suffer from shortness of breath when walking fast on level ground or walking up a slight
hill or incline (not related to weight or sedentary lifestyle)?
Yes
No
23.
Do you currently suffer from shortness of breath when walking with other people at an ordinary pace on
level ground (not related to weight or sedentary lifestyle)?
Yes
No
24.
Do you currently have to stop for breath when walking at your own pace on level ground (not related to
weight or sedentary lifestyle)?
Yes
No
25.
Do you currently suffer from shortness of breath when washing or dressing yourself (not related to
weight or sedentary lifestyle)?
Yes
No
26.
Do you currently suffer from shortness of breath that interferes with your job (not related to weight or
sedentary lifestyle)?
Yes
No
27.
Do you currently suffer from coughing that produces phlegm (thick sputum) (not related to weight or
sedentary lifestyle)?
Yes
No
28.
Do you currently suffer from coughing that wakes you early in the morning (not related to weight or
sedentary lifestyle)?
Yes
No
29.
Do you currently suffer from coughing that occurs mostly when you are lying down (not related to weight
or sedentary lifestyle)?
Yes
No
30.
Do you currently suffer from coughing up blood in the past month (not related to weight or sedentary
lifestyle)?
Yes
No
31.
Do you currently suffer from wheezing (not related to weight or sedentary lifestyle)?
Yes
No
32.
Do you currently suffer from wheezing that interferes with your job (not related to weight or sedentary
lifestyle)?
Yes
No
33.
Do you currently suffer from chest pain when you breathe deeply (not related to weight or sedentary
lifestyle)?
Yes
No
34.
Do you currently have any other symptoms that you think may be related to lung (e.g., sleep apnea)
(not related to weight or sedentary lifestyle)?
Yes
No
FEMA Form FF-008-FY-22-125 (2/22)
Page 2 of 5
Please mark “YES” or “NO” to the following questions.
35.
Have you ever had a heart attack?
If yes, date:
Yes
No
36.
Have you ever had a stroke?
If yes, date:
Yes
No
37.
Have you ever had angina? (chest pain)
If yes, date:
Yes
No
38.
Have you been diagnosed with heart failure?
If yes, date:
Yes
No
39.
Have you ever had swelling in your legs or feet (not caused by walking)?
Yes
No
40.
Have you ever had heart arrhythmia (irregular heartbeat, fast, slow, skipping)?
Yes
No
If yes, date:
If yes, describe any limitations or restrictions related to heart arrhythmia:
41.
Have you ever had high blood pressure?
Yes
No
42.
Have you ever had any other heart problem that you’ve been told about?
Yes
No
Yes
No
If yes, describe:
43.
DRAFT
Do you currently have any cardiovascular or heart-related limitations or restrictions?
If yes, describe:
44.
Are you currently under the care of a medical doctor for any condition related to pulmonary problems,
lung illness, heart, or cardiovascular problems?
Yes
No
45.
Have you ever had frequent pain or tightness in your chest?
Yes
No
46.
Have you ever had pain or tightness in your chest during physical activity?
Yes
No
47.
Have you ever had pain or tightness in your chest that interferes with your job?
Yes
No
48.
Have you ever had heartburn or indigestion not related to eating?
Yes
No
In the past two years, have you noticed your heart skipping or missing a beat?
Yes
No
Any other symptoms?
If yes, describe:
Yes
No
50.
Have you ever had eye irritation caused by using a respirator?
Yes
No
51.
Have you ever had skin allergies or rashes caused by using a respirator?
Yes
No
52.
Have you ever experienced anxiety while using a respirator?
Yes
No
53.
Have you ever experienced general weakness or fatigue while using a respirator?
Yes
No
Yes
No
If yes, describe:
49.
Any other problems that interfere with your use of a respirator:
54.
Have you ever been hospitalized or had surgery in the past year?
If yes, describe:
FEMA Form FF-008-FY-22-125 (2/22)
Page 3 of 5
Please mark “YES” or “NO” to the following questions.
55.
Have you ever lost vision in either eye temporarily or permanently?
Describe:
56.
If yes, date:
Yes
No
Do you currently wear contact lenses?
Yes
No
57.
Do you currently wear glasses?
Yes
No
58.
Are you color blind?
Yes
No
59.
Do you have any other eye or vision problems?
Yes
No
Yes
No
If yes, describe:
60.
Have you ever had an injury to your ears, including a punctured or ruptured eardrum?
If yes, date:
Describe:
DRAFT
61.
Do you currently have difficulty hearing?
Yes
No
62.
Do you currently wear a hearing aid?
Yes
No
63.
Do you currently have any other hearing or ear problems?
Yes
No
If yes, describe:
64.
Have you ever had a back injury?
If yes, date:
Describe any limitations or restrictions:
Yes
No
65.
Do you currently have weakness in any of your arms, hands, legs or feet?
Yes
No
66.
Do you currently have back pain?
Yes
No
67.
Do you currently have difficulty fully moving your arms and legs?
Yes
No
68.
Do you currently have pain or stiffness when you lean forward or backward at the waist?
Yes
No
69.
Do you currently have difficulty moving your head up and down?
Yes
No
70.
Do you currently have difficulty moving your head side to side?
Yes
No
71.
Do you currently have difficulty bending at your knees?
Yes
No
72.
Do you currently have difficulty squatting to the ground?
Yes
No
73.
Do you currently have difficulty climbing a flight of stairs of ladder carrying more than 25 pounds?
Yes
No
If yes, describe:
74.
Do you currently have any other muscle or skeletal problem that interferes with using a respirator?
Yes
No
75.
Do you normally wear any form of back brace or other form of brace or prosthesis?
Yes
No
Yes
No
If yes, describe:
76.
Will any of the muscle or skeletal problems listed above limit or prevent you from completing required
training?
FEMA Form FF-008-FY-22-125 (2/22)
Page 4 of 5
Please mark “YES” or “NO” to the following questions.
77.
Are you pregnant?
Yes
No
78.
Have you delivered a baby or experienced a miscarriage in the past 90 days?
Yes
No
79.
Do you have a medical condition that affects your immune system (i.e., lupus, rheumatoid arthritis,
cancer)?
Yes
No
80.
Have you ever served in the military?
Yes
No
81.
Would you like to speak to the Physician or Licensed Health Care Professional (PLHCP) who will review
this questionnaire?
Yes
No
82.
Do you currently take any medications for breathing or lung issues (e.g., inhalers, steroids, etc.)?
Yes
No
83.
Do you currently take any medications for heart symptoms?
Yes
No
84.
Do you currently take any medications for blood pressure?
Yes
No
85.
Do you currently take any medications for seizures (fits)?
Yes
No
86.
Do you currently take any medications for any other medical problems?
Yes
No
87.
Have you in the past taken corticosteroids for longer than 3 months at a time?
Yes
No
88.
Have you taken corticosteroids daily in the past 6 months?
Yes
No
89.
List all medications
Name of Medication
FEMA Form FF-008-FY-22-125 (2/22)
DRAFT
Frequency
Condition
Page 5 of 5
| File Type | application/pdf |
| File Title | FEMA Form FF-008-FY-22-125 |
| Subject | RESPIRATORY MEDICAL EVALUATION QUESTIONNAIRE FOR STUDENTS |
| Author | FEMA |
| File Modified | 2022-06-02 |
| File Created | 2022-06-02 |