Respirator Evaluation Questionnaire - Part A Section 2, Questions 1-3

Part A, Section 2 asks general health information and requires yes or no answers. The specific questions are as follows:

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?
   1. Seizures: Yes/No
   2. Diabetes (sugar disease): Yes/No
   3. Allergic reactions that interfere with your breathing: Yes/No
   4. Claustrophobia (fear of closed-in places): Yes/No
   5. Trouble smelling odors: Yes/No
3. Have you ever had any of the following pulmonary or lung problems?
   1. Asbestosis: Yes/No
   2. Asthma: Yes/No
   3. Chronic bronchitis: Yes/No
   4. Emphysema: Yes/No
   5. Pneumonia: Yes/No
   6. Tuberculosis: Yes/No
   7. Silicosis: Yes/No
   8. Pneumothorax (collapsed lung): Yes/No
   9. Lung cancer: Yes/No
   10. Broken ribs: Yes/No
   11. Any chest injuries or surgeries: Yes/No
   12. Any other lung problem that you've been told about: Yes/No

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