FIT Questionnaire

Respirator Medical Evaluation

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Section A. Current / Pre-Existing Conditions


Do you experience any seizures (fits)?

Do you have diabetes (sugar disease)?

Do you have any allergic reactions that interfere with your breathing?

Do you experience claustrophobia (fear of closed-in places)?

Do you have trouble smelling odors?
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Section B. Current / Pre-Existing Pulmonary or Lung Problems


Have you ever had or currently have Asbestosis?

Have you ever had or currently have Asthma?

Have you ever had or currently have Chronic Bronchitis?

Have you ever had or currently have Emphysema?

Have you ever had or currently have Pneumonia?

Have you ever had or currently have Tuberculosis?

Have you ever had or currently have Silicosis?

Have you ever had or currently have Pneumothorax (Collapsed Lung)?

Have you ever had or currently have Lung Cancer?

Have you ever had or currently have any Broken Ribs?

Have you ever had or currently have any Chest Injuries?

Have you ever had or currently have any lung problems you've been told about?
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Section C. Pulmonary & Lung Illness


Have you ever or do you currently experience any shortness of breath?

Have you ever or do you currently experience any shortness of breath when walking fast on level ground or walking up a slight hill or incline?

Have you ever or do you currently experience any shortness of breath when walking with other people at an ordinary pace on level ground?

Have you ever or do you currently experience having to stop for breath when walking at your own pace on level ground?

Have you ever or do you currently experience any shortness of breath when washing or dressing yourself?

Have you ever or do you currently experience any shortness of breath that interferes with your job?

Have you ever or do you currently experience any coughing that produces phlegm (thick sputum)?

Have you ever or do you currently experience any coughing that wakes you early in the morning?

Have you ever or do you currently experience any coughing that occurs mostly when you are lying down?

Have you ever or do you currently experience any coughing up blood in the last month?

Have you ever or do you currently experience any Wheezing?

Have you ever or do you currently experience any Wheezing that interferes with your job?

Have you ever or do you currently experience any chest pain when breathing deeply?

Have you ever or do you currently experience any symptoms that may be related to a lung problem?

Have you received steroid medication for your lung disease in the past year?

Have you been hospitalized for lung problems in the past year?
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Section D. Cardiovascular & Heart


Have you ever had a heart attack?

Have you ever had a stroke?

Have you ever had Angina?

Have you ever had heart failure?

Have you ever had swelling in your legs or feet (not caused by walking)?

Have you ever had Heart Arrhythmia (heart beating irregularly)?

Have you ever had High blood pressure?

Have you ever had any other heart problem that you've been told about?

Have you ever had frequent pain or tightness in your chest?

Have you ever had pain or tightness in your chest during physical activity?

Have you ever had pain or tightness in your chest that interferes with your job?

In the past two years, have you noticed your heart skipping or missing a beat?

Have you ever had heartburn or indigestion that is not related to eating?

Are there any other symptoms that you think may be related to heart or circulation problems?

Have you been hospitalized for heart problems in the past year?
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Section E. Medication


Are you currently taking any medication for Breathing or lung problems?

Are you currently taking any medication for Heart trouble?

Are you currently taking any medication for Blood pressure?

Are you currently taking any medication for Seizures (fits)?
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Section F. Respirator


Have you ever used a Respirator?
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Section G. Acknowledgement


Can you read and understand English?

Can you read and understand this questionnaire?

I hereby release the form and content of my respirator "Medical Evaluation Questionnaire (MEQ) to CITADEL CARE CENTERS and/or its representatives. This information may be reported to the physician or other licensed health care professional (PLHCP) as designated by CITADEL CARE CENTERS by e-mail, phone, fax or other method. I understand that the sole purpose of collecting and reviewing this form is to ensure that all persons are able to wear an appropriate respiratory protection device during the course of my normal employment activities or for the purposes of a drill or an actual emergency. I further understand that these evaluations are not meant, with regard to the candidate, to infer, construe or otherwise suggest any specific diagnosis nor is it an attempt to diagnose, cure or treat in any manner or by any means, methods, devices or instrumentalities, any disease, illness, pain, wound, fracture, infirmity, deformity, defect or abnormal physical or mental condition of any person. In the event that I do not pass this evaluation, I understand that it is up to me and/or my employer to contact an appropriate physician or other licensed health care professional to resolve this matter through further evaluation. I also understand that I will not be issued a Respiratory Fit Card until such time as I receive a medical clearance from either the CITADEL CARE CENTERS PLHCP, my personal physician or my employer.
Do you agree to terms and conditions stated above?

Submission Management

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COVID Vaccine Acknowledgements

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T-Shirt Size Submissions

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