Adult Respiratory - Exemed Online

Employee Details

Full Name (required)

DOB (required)//

Job Title (required)

Employer (required)

Address (required)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone (required)

1. Do you have a troublesome cough or bring up phlegm? (required)

Yes
No

i) Do you cough frequently during the day?

Yes
No

ii) Do you cough frequently during the night?

Yes
No

iii) Do you seem to cough more frequently at work than at home?

Yes
No

iv) Do you frequently bring up any phlegm from your chest?

Yes
No

v) Do you take anything for your cough/phlegm?

Yes
No

2. Do you suffer from shortness of breath? (required)

Yes
No

i) Is this related to exercise or physical activity?

Yes
No

ii) Is this related to cold weather?

Yes
No

iii) Is your shortness of breath worse at work?

Yes
No

3. Does your chest ever sound wheezy or whistling? (required)

Yes
No

i) Is this related to exercise or physical activity?

Yes
No

ii) Is this related to cold weather?

Yes
No

iii) Is your wheezing worse at work?

Yes
No

iv) Does your wheezing get worse in a dusty or smoky room?

Yes
No

v) Do you ever wake with wheezing or shortness of breath?

Yes
No

4. Do you ever experience chest tightness? (required)

Yes
No

i) Does this also cause you to be short of breath? (required)

Yes
No

ii) Are you wheezy with chest tightness? (required)

Yes
No

iii) Do you have chest tightness related to physical activity? (required)

Yes
No

iv) Do you experience chest tightness at work? (required)

Yes
No

5. Do you have episodes of blocked, itchy or runny nose? (required)

Yes
No

i) Does being at work seem to make this worse? (required)

Yes
No

ii) Do you have nasal polyps or other obstruction to the nose? (required)

Yes
No

iii) Have you had treatment or surgery to the nose? (required)

Yes
No

6. Have you experienced your eyes becoming red, itchy or sore? (required)

Yes
No

i) Is this a frequent problem? (required)

Yes
No

ii) Does it seem to be worse at work? (required)

Yes
No

iii) Does it seem to be related to a particular time of the year? (required)

Yes
No

7. Do you have any allergies? (required)

Yes
No

Specify

8. Do you smoke? (required)

Yes
No

i) specify what and how much?

ii) If Ex-smoker say when stopped.

9. Have you ever consulted a doctor about breathing symptoms? (required)

Yes
No

i) Were you told you had asthma?

Yes
No

ii) Was it a chest infection, bronchitis, pleurisy or T.B.?

Yes
No

10. Have you ever had a severe chest injury? (required)

Yes
No

Please specify

11. Have you ever had chest surgery? (required)

Yes
No

Please specify

12. Do you take medication for breathing/eye/nose symptoms? (required)

Yes
No

Please specify

13. Have you been exposed to respiratory allergens (eg paints, welding, asbestos etc)? (required)

Yes
No

i) Please specify

ii) Did you receive Health Surveillance? (required)

Yes
No

iii) Did you develop any health problems? (required)

Yes
No

iv) Has a Doctor diagnosed Occupational Asthma? (required)

Yes
No

14. How long have you worked for your present company?

15. Do you know what respiratory dangers there are in your present job (eg fumes, dust, paints, welding)? (required)

Yes
No

Please Specify

16. Do you have to take time off work for respiratory problems? (required)

Yes
No

i) How many days off work in the last year?

ii) Are your respiratory problems better when away from work? (required)

Yes
No

17. Are you given any respiratory protection at work? (required)

Yes
No

i) Do you always wear the protection when required to do so? (required)

Yes
No

18. How is your respiratory health at present? (required)

Good
Fair
Poor
Getting worse

Declaration

I declare that the answers given in this form are true to the best of my knowledge and belief. I consent to information regarding the state of my respiratory system being passed to my employer. I consent to ExeMed processing and holding this information under the Data Protection Legislation.

Date

Adult Respiratory Questionnaire